Intra arterial hepatic chemotherapy for unresectable colorectal metastases: (review)

BACKGROUND

Hepatic arterial infusion (HAI) chemotherapy is based on the idea that liver metastases are perfused almost exclusively by the hepatic artery. This approach has been extensively investigated in 1970s and 1980s. Currently, there is a worldwide growing interest in intraarterial therapeutic approaches for hepatic metastases. The principal aim of this review was to define current role of HAI in the management of metastatic colorectal cancer.

METHODS

Data for this review were identified by searches of MEDLINE using the search terms "hepatic arterial infusion", "colorectal cancer" and "chemotherapy". Abstracts and reports from meetings were included only when they related directly to previously published work. Only papers published in English between 1966 and 2005 were included.

RESULTS AND CONCLUSION

There are 10 published randomised clinical trials comparing fluoropyrimidine-based HAI with systemic route. Two meta-analyses of the earlier 7 trials confirmed a statistically significant response rate and improved disease-free survival with HAI. However, the cost and complication rates were of primary concern. The last decade witnessed the introducztion of new chemotherapeutic regimens including biologically targeted agents for the management of metastatic colorectal cancer patients and advancement in radiological and surgical techniques. These led to reconsideration of HAI-based therapeutic modalities with many running trials addressing its value in this new era. The results of these trials may help to clarify the role of HAI in the near future.

EXIBIT: An international multicenter phase II trial of gemcitabine and oxaliplatin (GEMOX) in patients with advanced biliary tract cancer

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Background: Biliary tract carcinomas (BTC) are often diagnosed at an advanced/metastatic stage and have a poor prognosis. The combination of gemcitabine and oxaliplatin (GEMOX) showed promising activity in a French Phase II study (4 centers) in advanced BTC (André. Ann Oncol 2004;15:1339–1343). The objective of this study is to further evaluate the efficacy and safety of GEMOX as first-line therapy in patients (pts) with advanced BTC. Methods: Eligible pts were >18 years of age with histologically proven and measurable, locally advanced or metastatic BTC, had an ECOG PS ≤ 2, adequate renal and hematologic functions, bilirubin < 2.5 × upper limit of normal, and no prior malignancy or brain metastases. Gemcitabine 1000 mg/m2 (Day 1) and oxaliplatin 100 mg/m2 (Day 2) were administered every 2 weeks. The primary objective was response rate (RR) by RECIST (one dimension); secondary objectives were progression-free survival (PFS), overall survival (OS), and safety. Here we report an interim analysis of OS and safety. Results: A total of 70 pts were enrolled between April 2003 and April 2005. The median age was 62 years (range 30–83), 40.0% of pts were male, 94.3% had ECOG PS 0–1. Tumor sites were intrahepatic bile ducts (37.1%), gallbladder (31.4%), extrahepatic bile ducts (12.9%), ampulla of Vater (1.4%), intra/extrahepatic bile ducts (1.4%), missing data (15.7%); 98.6% of pts had no prior radiotherapy and 50% had no prior surgery for BTC. Median OS is 8.25 months (68% of pts are dead and 32% have censored data). Sixty-seven pts were evaluable for safety. Grade 3/4 (NCI-CTC v. 2) hematologic toxicities (% of pts) included thrombocytopenia 10.4%, anemia 9.0%, and neutropenia 9.0%. One pt had febrile neutropenia. Grade 3/4 nonhematologic toxicities included pain 10.4%, ALT elevation 9.0%, fatigue 9.0%, infection 10.4%, vomiting 9.0%, sensory neuropathy 4.5%, nausea 4.5%, and diarrhea 3.0%. One patient died during treatment (cause unknown). Conclusions: GEMOX has acceptable toxicity in pts with BTC. Updated efficacy data (RR, PFS, and OS for the entire population and also by tumor sites) will be presented at the meeting.

[Table: see text]

Polymorphisms within the lactoferrin gene promoter in various cattle breeds

Lactoferrin (Lf) is an iron-binding protein and belongs to the serum transferrin family. It has broad spectrum antimicrobial action, and it is found in exocrine secretions including milk. The sequence of the bovine lactoferrin gene promoter was analyzed in five different cattle breeds (Holstein Friesian, New Zealand Holstein, Montebéliard, Normande, and Norwegian Red) to determine the extent of polymorphic variation, which exists in this region both within and across cattle breeds. Fifteen different single nucleotide polymorphisms (SNPs) were identified throughout this region. Numerous polymorphisms were found throughout the Holstein Friesian, New Zealand Holstein, Montebéliard, and Normande populations. The most frequently encountered polymorphism found in all breeds was at position -28, which is immediately proximal to the TATA box of the promoter. The most variable base position was -131, which included three types of heterozygotes including a single base deletion in one allele, and three homozygote variants. This polymorphism occurs in a putative transcription factor binding site, for the nuclear factor of activated T cells (NF-ATc). A unique polymorphism was identified in one Normande animal, and three polymorphisms were found in one Montebéliard animal. In general, Norwegian Red cattle displayed fewer SNPs than other breeds. Most nucleotide changes in these animals were within the 190 base pairs of the transcription start point, with the exception of an insertion seen in three animals at position -478. In conclusion, SNPs were found in abundance throughout this regulatory region. Whether or not these polymorphisms have an effect on the regulation of the bovine lactoferrin gene is yet to be elucidated. However, the identification of lactoferrin promoter variants may serve as a marker for healthier animals, thereby accelerating the improvement of animals through breeding.

184 EFFECT OF LIVE CONFOCAL FLUORESCENCE IMAGING ON EMBRYONIC DEVELOPMENT

The aim of this study was to examine the effects of fluorescent confocal imaging on embryo development. DNA damage, caspase activation, and reactive oxygen species (ROS) production were also measured. In vitro-generated bovine 8-cell embryos and in vivo-produced mouse 2-cell embryos were stained with Mitotracker Red and individually imaged using a spinning-disc confocal module (CARV) attached to a Nikon TE2000-U microscope. The sample was excited with a 120 W metal halide lamp (X-Cite 120) using a fluorescent filter set (Excitation: 575 nm; Emission: 640 nm). A variety of number and durations of exposures were tested. Continuous variables were analyzed by t-test, whereas categorical data were analyzed using the homogeneity chi square test. Bovine embryos showed no differences in blastocyst development (Day 7.5; Day 0 = IVF) or hatched blastocysts (Day 11) between groups of imaged and non-imaged embryos (Table 1). Despite numerous attempts, we were unable to find a level of exposure that disturbed embryo development, indicating that bovine embryos have a high degree of tolerance to the imaging system. After exposure, mouse embryos were cultured in vitro to the blastocyst stage and transferred into surrogate synchronized females. Embryos subjected to five exposures of 50 ms developed normally both in vitro and in vivo (Table 1). However, exposing the embryos 30 times significantly affected in vitro and in vivo development. Subsequently, we examined the effect of confocal imaging on DNA damage (Comet assay), ROS production (dichlorofluoresceindiacetate, DCF), and caspase 3 activation (PhiPhiLux®-G1D2). Bovine embryos were exposed to 60z–50 ms or 60z–500 ms, and mouse embryos to 5z–50 ms or 30z–50 ms after Mitotracker Red staining. We observed that caspase 3 was not activated when measured 1.5 h after imaging. Similarly, DNA damage was not different among embryos exposed at different levels of imaging. However, ROS production significantly increased in both bovine and mouse embryos after exposure to confocal imaging, and this increase correlated with fluorescence exposure level. We conclude that imaging bovine pre-implantation embryos with this system increased ROS production but did not disturb in vitro development (even at unnecessary high levels of exposure). In mouse embryos, in vitro development after imaging directly correlated with in vivo development. It remains to be determined whether the increase in ROS production and decreased developmental potential is due to the fluorescence exposure alone or the combined effect of fluorescence exposure and Mitotracker labeling. Table 1. Embryonic development after confocal fluorescence imaging

24 GLOBAL TRANSCRIPT PROFILING OF CLONED BOVINE BLASTOCYSTS USING AFFYMETRIX GENECHIP TECHNOLOGY

Identification of genes implicated in the biological processes of somatic cell nuclear transfer will improve our understanding of reprogramming events, i.e. the transformation of a lineage-committed cell into a pluripotent one. In addition, the gene expression profile of cloned embryos can help explain the widely reported developmental failures in cloned animals. In this study, we investigated global gene expression profiles of bovine in vitro-fertilized and cloned embryos using Gene Chip Bovine Genome Arrays (Affymetrix, Inc., Santa Clara, CA, USA). For the generation of cloned bovine blastocysts from two adult fibroblast lines (C and D), we employed methods previously proven to generate live offspring and compared these offspring to in vitro-produced blastocysts. Total RNA isolated from groups of 10 blastocysts was amplified by a template-switching PCR. Amplified cDNAs were used to synthesize biotin-labeled antisense RNAs (aRNAs) during and in vitro transcription reaction. Labeled aRNAs were hybridized to microarrays as described by the manufacturer. Experiments were performed in four replicates. Expression data were analyzed using the Significance Analysis of Microarrays (SAM; Tusher et al. 2001 Proc. Natl. Acad. Sci. 98, 5116-5121) procedure and software. Overall, 48.4% and 46% of 23 000 bovine transcripts spotted on the arrays were present in cloned and in in vitro-produced control blastocysts, respectively. The SAM procedure identified 43 genes that changed at least 1.5-fold, with an estimated false discovery rate (FDR) of 20%. Comparison of gene expression between NT embryos produced from two different cell lines and IVF controls with the same criteria revealed 6 (clones from cell line C vs. IVF) and 46 (clones from cell line D vs. IVF) differentially expressed genes. The number of transcripts expressed differentially between the cloned embryos with different donor cell origin was 437. Of the 43 differentially expressed transcripts in cloned blastocysts, 13 have unknown functions and the rest of the genes related to cell structure (tuftelin, desmoplakin), cell cycle/mitosis (Kinesin like 4, katanin, stathmin, PCNA), energy metabolism (lactate dehydrogenase, ATPsynthase, lipid-binding protein, keto acid dehydrogenase E1, metallothionein), and cell signaling (GTP-binding protein1, GTP binding stimulatory protein). Our results indicate that expression profiles of cloned blastocysts could be affected by somatic donor cell.

Efficacy of 5-fluorouracil-based chemotherapy in elderly patients with metastatic colorectal cancer: a pooled analysis of clinical trials

BACKGROUND

Recently published population-based investigations showed elderly patients to be underrepresented in clinical trials and less often treated according to the standard therapy. Although there is evidence that elderly patients benefit from adjuvant (radio-) chemotherapy to the same extent as younger patients, no large series describes the influence of age on efficacy of chemotherapy in metastatic colorectal cancer.

PATIENTS AND METHODS

We carried out a retrospective analysis using source data of 3825 patients who received 5-fluorouracil (5-FU)-containing treatment in 22 European trials and identified 629 patients with an age of > or = 70 years.

RESULTS

We found an equal overall survival in elderly patients [10.8 months, 95% confidence interval (CI) 9.7-11.8] and in younger patients (11.3 months, 95% CI 10.9-11.7; P = 0.31). Response rate did not differ between age groups > or = 70 and <70 years (23.9% and 21.1%; respectively; P = 0.14). Progression-free survival was marginally prolonged in elderly patients (5.5 months, 95% CI 5.2-5.8; compared with 5.3 months, 95% CI 5.1-5.5; P = 0.01). In both age groups, infusional 5-FU resulted in significantly increased response rates, overall survival and progression-free survival compared with bolus 5-FU.

CONCLUSIONS

'Fit' elderly patients benefit at least to the same extent from palliative chemotherapy with 5-FU as younger patients. Infusional 5-FU was shown to be more effective than bolus 5-FU in both age groups. Therefore, standardized palliative chemotherapy should generally be offered to elderly patients and they should not be excluded from clinical trials.

272 OOCYTE SPONTANEOUS ACTIVATION IN DIFFERENT RAT STRAINS

Oocyte spontaneous activation (OSA) has been reported to occur during in vitro culture of ovulated rat eggs. Approximately 1.5 h after isolation and culture, unfertilized oocytes extrude the second polar body and enter a metaphase arrest, and by 3 h individual chromatids separate and scatter throughout the egg's cytoplasm. The objective of this study was to compare the proportion of OSA and the level of maturation promoting factor (MPF) activity in oocytes from different strains. Twelve strains were selected from two commercial sources based on litter size. Mature female rats (9 to 12 weeks old) were superovulated using 20 IU eCG s.c. followed by 30 IU eCG s.c. 5 h later. After 48 h, a dose of 50 IU hCG was administered intraperitonealy and females were mated with vasectomized males. Oocytes were collected 17 h after hCG injection and cumulus cells were removed by transfer to M2 medium containing hyaluronidase (1 mg mL−1). Denuded oocytes were cultured in 50 μ­L drops of M16 medium under oil at 37°C and 5% CO2 in air. In order to assess OSA, oocytes were mounted in glycerol containing Hoechst 33342 (10 μg mL−1) on a glass slide after 6 h of in vitro culture. The proportion of activated oocytes was determined by epifluorescence microscopy. Oocytes were considered to be in metaphase II if they presented a compact group of chromosomes at the metaphase plate, and were considered activated when chromosome dispersion at different degrees was observed. Data were analyzed by ANOVA, considering each animal as an experimental unit. Significant differences were observed between strains (P < 0.01, Table). In order to determine MPF activity of each strain, 10 oocytes were removed from culture at 0, 1.5, and 3 h after oocyte collection and immediately stored in kinase buffer in LN2 for posterior analysis using an ELISA based kit (MESACUP cdc2 Kinase Assay Kit, MBL, Nagoya, Japan). The log ratio of the MPF activity at 1.5 and 3 h relative to 0 h for each animal (5 per strain) was analyzed by ANOVA. There were no MPF differences between or within strains (P > 0.3 and P > 0.05, respectively). We did not observe the expected decrease in MPF activity that allows for the exit of metaphase II arrest. This could imply that OSA is not associated with a decrease in MPF, or that MPF decreased rapidly and returned to metaphase levels by 1.5 h after culture. In conclusion, different levels of OSA were observed between strains, however, no differences in MPF activity were detected at the analyzed time points.

95 EFFECT OF ESTROUS COW SERUM ON SURVIVAL OF IN VITRO-PRODUCED BOVINE EMBRYOS AFTER SLOW FREEZING OR VITRIFICATION

Until now, the major obstacle associated with the extensive use of in vitro-produced bovine embryos is the lack of suitable methods to cryopreserve them. At least two approaches exist for overcoming this problem. One is to adjust cryopreservation methods to the requirements of these embryos, and the other is to improve embryo quality by using an appropriate in vitro environment for embryo production. The objective of this study was to determine the effect of estrous cow serum (ECS) during in vitro culture on embryo survival after cryopreservation by slow freezing or vitrification. Cumulus-oocytes complexes were in vitro-matured and fertilized as previously described (Ferre et al. 2003 Theriogenology 59, 301 abst). Presumptive zygotes were denuded from cumulus cells and cultured in groups of 50 in 400 μL drops of CR1aa medium. Seventy-two hour post-insemination (PI) embryos were randomly separated into three groups. Each group was then cultured in CR1aa + 5% ECS (without BSA; CR1-ECS), CR1aa + 3 mg/mL BSA (CR1-BSA), or CR1aa + 5% ECS + 3 mg/mL BSA (CR1-ECS-BSA). Embryos were cultured under 38.5°C, 5% CO2, 5% O2, and 90% N2. At 7.5 days PI, blastocysts from each group were double stained using propidium iodide and bisbenzimide (Hoechst 33342) to determine damaged cells and total cell number. The remaining embryos were randomly cryopreserved by freezing (1.5 M ethylene glycol; cooled at 0.5°C/min to −35°C) or vitrification (open pulled straw, Vajta et al. 1998 Mol. Reprod. Dev. 51, 53–58). After thawing or warming, embryos were cultured in CR1-ECS-BSA to evaluate embryo survival (hatching rate). Data were analyzed by χ2, ANOVA and Student's t-test (SAS Institute, Inc., Cary, NC, USA). Total cell number was higher in embryos cultured in CR1-ECS than in CR1-BSA or CR1-ECS-BSA (CR1-ECS: 142.1 ± 4.7, n = 23 vs. CR1-BSA 124.7 ± 4.9, n = 21, and CR1-ECS-BSA 125.8 ± 4.5, n = 25; t-test, P < 0.05). No differences were found in percent of damaged cells (CR1-ECS: 0.7%; CR1-BSA: 1.8%; CR1-ECS-BSA: 0.7%). Blastocyst survival after thawing was affected by cryopreservation methods and culture media (P < 0.01, Table 1). No interaction was found between both factors. In conclusion, under our experimental conditions elimination of ECS from CR1aa medium improves embryo cryotolerance. Vitrification allows for higher survival rates, regardless of the presence of serum during embryo culture. Table 1. Effect of cryopreservation method and serum supplementation during embryo culture on survival rate of in vitro-produced bovine embryos

Suppression of α-Cyano-4-hydroxycinnamic Acid Matrix Clusters and Reduction of Chemical Noise in MALDI-TOF Mass Spectrometry

Progress in high-throughput MALDI-TOFMS analysis, especially in proteome applications, requires development of practical and efficient procedures for the preparation of proteins and peptides in a form suitable for high acquisition rates. These methods should improve successful identification of peptides, which depends on the signal intensity and the absence of interfering signals. Contamination of MALDI samples with alkali salts results in reduced MALDI peptide sensitivity and causes matrix cluster formation (widely reported for CHCA matrix) observed as signals dominating in the range below m/z 1200 in MALDI spectra. One way to remove these background signals, especially for concentrations of peptides lower than 10 fmol/microL, is to wash matrix/sample spots after peptide cocrystallization on the MALDI plate with deionized water prior to analysis. This method takes advantage of the low water solubility of the CHCA compared to its alkali salts. We report here that the application of some ammonium salt solutions, such as citrates and phosphates, instead of deionized water greatly improves the efficiency of this washing approach. Another way to reduce matrix cluster formation is to add ammonium salts as a part of the MALDI matrix. The best results were obtained with monoammonium phosphate, which successfully suppressed matrix clusters and improved sensitivity. Combining both of these approaches-the addition of ammonium salts in the CHCA matrix followed by one postcrystallization washing step with ammonium buffer-provided a substantial ( approximately 3-5-fold) improvement in the sensitivity of MALDI-MS detection compared to unwashed sample spots. This sample preparation method resulted in improved spectral quality and was essential for successful database searching for subnanomolar concentrations of protein digests.

Commissioning and clinical results utilizing the Gildenberg-Laitinen Adapter Device for X-ray in fractionated stereotactic radiotherapy

BACKGROUND

The Gildenberg-Laitinen Adapter Device for X-Ray (GLAD-X/LS) frame is a positioning device that allows the use of the same fiducial points as the Brown-Robert-Wells (BRW) system. Thus it permits treatment planning to be accomplished by the Radionics X-knife Radiosurgery Program. We investigated the commissioning and clinical benefits of the GLAD-X/LS for fractionated stereotactic radiotherapy (FSRT) in patients who were unable to tolerate the Gill-Thomas-Cosman (GTC) frame.

METHODS AND MATERIALS

Commissioning of the GLAD-X/LS system was done via use of a Rando Phantom. A target volume of 2 x 2 x 2 cm was drilled into the phantom head. An ion chamber and thermoluminescence dosimetric chips (TLDs) were implanted in the target. A simulated treatment course consisting of 5 stereotactic radiotherapy fractions (300 cGy, 30 mm collimator) was delivered to the phantom head. A total of 27 patients who could not tolerate the GTC frame were treated using the GLAD-X/LS system. A total of 35 isocenters were used; the median number of treatment fractions was eight. Reproducibility of the x, y, and z coordinates was examined and correlated to the same determined using orthogonal port films. Relocation accuracy and reproducibility were further assessed comparing the x, y, and z coordinates of the target center with multiplanar reconstructed coronal and sagittal images. Patient tolerance of the device was also evaluated daily throughout the treatment.

RESULTS

The measured TLD and ion chamber doses were within 3% of the prescribed dose at the isocenter. The same dose accuracy was also found at incremental distances of 5 mm, 10 mm, and 15 mm from the isocenter. All patients tolerated the treatment and the device well. Six patients experienced mild ear canal pain, and softer or smaller earpieces were substituted. The mean relocation accuracy was 1.5 mm +/- 0.8.

CONCLUSIONS

The GLAD-X/LS system has excellent accuracy and reproducibility with the mean relocation accuracy of 1.5 mm +/- 0.8. The device is well-tolerated by patients, with no significant complications. Larger scale studies are necessary before routine use can be recommended for the administration of FSRT.

Hyperfractionated radiotherapy and paclitaxel for locally advanced/unresectable pancreatic cancer

PURPOSE

To determine prospectively the maximal tolerated dose and potential antitumor activity of weekly paclitaxel with concurrent hyperfractionated radiotherapy in patients with locally advanced and/or unresectable pancreatic cancer.

METHODS AND MATERIALS

We embarked on Phase I-II study of hyperfractionated radiotherapy using a concomitant in-field boost to a total dose of 63.80 Gy in 6 weeks at 1.1 Gy/fraction. Paclitaxel was administered weekly on Days 1, 8, 15, 22, 29, and 36 as a 3-h infusion. Paclitaxel doses were escalated from 20 mg/m(2)/wk to 70 mg/m(2)/wk. Twenty patients were studied, 14 women and 6 men (mean age 64 years). Some patients presented with one or more symptoms. Obstructive jaundice was the main presenting symptom in 10 patients and epigastric pain in 14. All patients had unresectable histologically proven adenocarcinoma of the pancreas (15 head, 4 body, and 1 tail). Reasons for unresectability were involvement of the portal vein, and/or superior mesenteric artery (n = 14), paraaortic nodes (n = 8), and medically inoperable (n = 1). Fourteen patients underwent a biliary bypass procedure before treatment (four endoscopic stenting, five choledochojejunostomy, and five cholecystojejunostomy). The follow-up period ranged from 14 to 66 months (median 44).

RESULTS

The dose-limiting toxicity was observed at 70 mg/m(2)/wk. Grade IV Radiation Therapy Oncology Group late GI toxicity was seen in 1 patient in the form of duodenal stricture and hemorrhage. Grade II gastrointestinal adverse effects occurred in 13 patients and Grade 3 in 1 patient. No neurologic morbidity was encountered. Eight patients required cytokine support for Grade 2 and 3 neutropenia. The treatment course was delivered within the planned time in 80% of the patients. Complete relief of pain occurred in 10 of 14 patients. The CA 19-9 level was either stable or decreasing in 12 of 15 patients. Of 17 assessable patients, stable disease was seen in 10, regression in 2, a partial response in 3, and a complete response in 2.

CONCLUSION

The use of hyperfractionated radiotherapy to a dose of 63.80 Gy with concomitant weekly paclitaxel is tolerated. The maximal tolerated dose of paclitaxel for this study was 60 mg/m(2)/wk. The preliminary objective responses denote activity of the regimen. We recommend testing this regimen in larger scale studies.

Global distribution of halogenated dimethyl bipyrroles in marine mammal blubber

Four halogenated dimethyl bipyrroles (HDBPs), hypothesized to be naturally produced, were quantitated in marine mammal blubber from a number of species obtained from various locations worldwide. HDBPs were found in samples from all locations studied. Concentrations of total HDBPs (SigmaHDBPs) ranged from 0.4 ng/g lipid weight in ringed seals (Phoca hispida) from the White Sea to 2,540 ng/g lipid weight in Dall's porpoise (Phocoenoides dalli) from the northwestern North Pacific Ocean. At their highest levels, SigmaHDBPs made up 11% of the total quantitated organohalogen body burden of adult male Dall's porpoises. In two beluga (Delphinapterus leucas) data subsets, it was found that males contained significantly higher concentrations of SigmaHDBPs than females. No significant effects of age or sex on SigmaHDBPs were observed in harbor seal (Phoca vitulina) and bowhead whale (Balaena mysticetus) data subsets. The geographical distribution of concentrations did not resemble that of the ubiquitous anthropogenic organohalogen, polychlorinated biphenyl congener CB-153. Higher concentrations of HDBPs and different patterns of congeners were observed in samples from Pacific as opposed to non-Pacific Ocean influenced environments. Concentrations of HDBPs in beluga from the Arctic and St. Lawrence River were similar. Their high abundance in north Pacific Ocean biota and widespread occurrence suggest that HDBPs undergo extensive transport from a source located primarily in the Pacific Ocean. Evidence from HDBP congener patterns indicates that both ocean currents and atmospheric transport likely play a role in the movement of HDBPs. These results imply that HDBPs and anthropogenic organohalogens have different sources and support the natural production hypothesis.

Prospective randomized trial comparing mitomycin, cisplatin, and protracted venous-infusion fluorouracil (PVI 5-FU) With epirubicin, cisplatin, and PVI 5-FU in advanced esophagogastric cancer

PURPOSE

We report the results of a prospectively randomized study that compared the combination of epirubicin, cisplatin, and protracted venous-infusion fluorouracil (PVI 5-FU) (ECF) with the combination of mitomycin, cisplatin, and PVI 5-FU (MCF) in previously untreated patients with advanced esophagogastric cancer.

PATIENTS AND METHODS

Five hundred eighty patients with adenocarcinoma, squamous carcinoma, or undifferentiated carcinoma were randomized to receive either ECF (epirubicin 50 mg/m(2) every 3 weeks, cisplatin 60 mg/m(2) every 3 weeks and PVI 5-FU 200 mg/m(2)/d) or MCF (mitomycin 7 mg/m(2) every 6 weeks, cisplatin 60 mg/m(2) every 3 weeks, and PVI 5-FU 300 mg/m(2)/d) and analyzed for survival, response, toxicity, and quality of life (QOL).

RESULTS

The overall response rate was 42.4% (95% confidence interval [CI], 37% to 48%) with ECF and 44.1% (95% CI, 38% to 50%) with MCF (P =.692). Toxicity was tolerable, and there were only two toxic deaths. ECF resulted in more grade 3/4 neutropenia and grade 2 alopecia, but MCF caused more thrombocytopenia and plantar-palmar erythema. Median survival was 9.4 months with ECF and 8.7 months with MCF (P =.315); at 1 year, 40.2% (95% CI, 34% to 46%) of ECF and 32.7% (95% CI, 27% to 38%) of MCF patients were alive. Median failure-free survival was 7 months with both regimens. Global QOL scores were better with ECF at 3 and 6 months.

CONCLUSION

This study confirms response, survival, and QOL benefits of ECF observed in a previous randomized study. The equivalent efficacy of MCF was demonstrated, but QOL was superior with ECF. ECF remains one of the reference treatments for advanced esophagogastric cancer.

The use of AEDs by police officers in the City of London. Automated external defibrillators

The Guidelines 2000 for cardiopulmonary resuscitation recommend shock delivery to victims in ventricular fibrillation within 5 min of call receipt by the Emergency Medical Services. In an effort to achieve this goal, in some parts of the United States, police officers have been trained to use automated external defibrillators (AEDs). We undertook a 3-year pilot evaluation of the use of AEDs by City of London police (CPOL) officers. Over a period of 3 years, 147 CPOL officers were trained in the use of an AED. Four AEDs were placed on rapid response vehicles covering the City of London. An overall call-response interval target was set at 8 min. The CPOL attended 1103 (90%) of the total of 1232 calls to which they were summoned. The mean interval between the first call received and arrival of the CPOL on scene was 8.9+/-4.0 min. The CPOL applied AEDs to 25 victims, 13 of whom were initially in ventricular fibrillation; at least one shock was delivered to all 13. The interval between call reception and delivery of the first shock was 5.5+/-2.5 min. The mean interval between switching on the AED and delivery of the first shock was 24+/-12 s. Two (15%) of these victims survived to hospital discharge. This study has confirmed the feasibility of training police officers in the UK to use AEDs as first responders. The call received to arrival on scene interval should be reduced by improvements in communication between LAS and CPOL.