Endocrine changes in male HIV patients

AIMS AND OBJECTIVES

To determine the frequency of adrenal, thyroid and gonadal dysfunction in HIV positive male patients and to evaluate the endocrine function at different level of CD4 cell counts.

MATERIAL AND METHODS

A total of 150 male HIV positive subjects were included in study. The patients were divided in three groups on the basis of CD4 cell counts. "Group A": HIV positive with CD4 count<200/mm "Group B": HIV positive with CD4 count 200-350/mm3 and "Group C": HIV positive with CD4 count>350/mm3.

RESULTS

In "group A" (n=50) 2 patients had basal cortisol<5 microg/dl while 23 patients had basal cortisol>25 microg/ dl. 15 patients had subclinical hypothyroidism while 11 patients had overt hypothyroidism. 25 patients in this group had gonadal dysfunction: majority of them (24) had primary gonadal dysfunction (elevated LH). None of the patients in "group B" (n=50) had hypocortisolism while 11 patients had elevated cortisol; 18 had subclinical hypothyroidism while 4 had overt hypothyroidism while 17 patients were hypogonad, all having elevated LH. In "group C" (n=50) 2 patients had hypocortisolism and 5 had elevated cortisol; 12 patients had subclinical and one had overt hypothyroidism; 7 patients had primary hypogonadism and one had secondary hypogonadism. Overall 4(2.66%) had hypocortisolism while 39 (26%) had elevated cortisol; 45 (30%) had subclinical hypothyroidism while 16(10.66%) had overt hypothyroidism. Gonadal dysfunction was observed in 50 patients (33%) majority of them (48) had primary hypogonadism. On analysis of Pearson's correlation coefficient CD4 count has strong inverse correlation with basal cortisol (r=-0.301, p<0.0001), TSH (r=-0.257, p=0.002) and LH (r=-0.228, p=0.006), while there was a direct correlation with serum testosterone (r=0.175, p=0.037).

CONCLUSION

This pilot study has demonstrated a high incidence of endocrine dysfunction in HIV infected patient in this part of country. High incidence of thyroid and gonadal dysfunction may contribute to morbidity of the patients and have a bearing on quality of life of the HIV infected patients. Hypocortisolism was not that common but high level of cortisol may be a marker of stress due to HIV per se or due to associated infection. Many of these dysfunctions might be transient and a large longitudinal study should be undertaken to substantiate the finding of the present study.

Novel anaerobic digestion process with sludge ozonation for economically feasible power production from biogas

A novel process scheme was developed to achieve economically feasible energy recovery from anaerobic digestion. The new process scheme employs a hybrid configuration of mesophilic and thermophilic anaerobic digestion with sludge ozonation: the ozonated sludge is first degraded in a thermophilic digester and then further degraded in a mesophilic digester. In small-scale pilot experiments of the new process scheme, degradation of VSS improved by 3.5% over the control (mesophilic-only configuration) with 20% less ozone consumption. Moreover, biogas conversion also improved by 7.1% over the control. Selective enrichment of inorganic compounds during centrifugation produced a dewatered sludge cake with very low water content (59.4%). This low water content in the sludge cake improved its auto-thermal combustion potential during incineration and added to the overall energy savings. We conducted a case study to evaluate power generation from biogas for a municipal wastewater treatment plant with an average dry weather flow of 43,000 m3/d. Electricity production cost was 5.2 ¢/kWh for the advanced process with power generation, which is lower than the current market price of 7.2 ¢/kWh. The new anaerobic digestion scheme with power generation may reduce greenhouse gas emissions by about 1,000 t-CO(2)/year compared with the conventional process without power generation.

Potential of Complementary and Alternative Medicine in Preventive Management of Novel H1N1 Flu (Swine Flu) Pandemic: Thwarting Potential Disasters in the Bud

The emergence of novel H1N1 has posed a situation that warrants urgent global attention. Though antiviral drugs are available in mainstream medicine for treating symptoms of swine flu, currently there is no preventive medicine available. Even when available, they would be in short supply and ineffective in a pandemic situation, for treating the masses worldwide. Besides the development of drug resistance, emergence of mutant strains of the virus, emergence of a more virulent strain, prohibitive costs of available drugs, time lag between vaccine developments, and mass casualties would pose difficult problems. In view of this, complementary and alternative medicine (CAM) offers a plethora of interesting preventive possibilities in patients. Herbs exhibit a diverse array of biological activities and can be effectively harnessed for managing pandemic flu. Potentially active herbs can serve as effective anti influenza agents. The role of CAM for managing novel H1N1 flu and the mode of action of these botanicals is presented here in an evidence-based approach that can be followed to establish their potential use in the management of influenza pandemics. The complementary and alternative medicine approach deliberated in the paper should also be useful in treating the patients with serious influenza in non pandemic situations.

Extramedullary paraspinal hematopoiesis in hereditary spherocytosis

Hereditary spherocytosis (HS) is a common inherited hemolytic anemia due to red cell membrane defects. Extramedullary hematopoiesis is a compensatory response to insufficient bone marrow blood cell production. The preferred sites of extramedullary hematopoietic involvement are the spleen, liver and lymph nodes; but in HS, the posterior paravertebral mediastinum is also commonly involved. We report a case of a 50-year-old male who presented to us in respiratory distress and with bilateral paravertebral posterior mediastinal masses, which on trucut biopsy were found to be extra-hematopoietic masses; and the patient was found to have hereditary spherocytosis.

Molecular Enhancement of Thermal Ablation Therapies Using TNF-α-Coated Gold Nanoparticles in a Translational Model of Renal Tumors

Thermal ablation therapies are currently used for the treatment of select renal masses. Such treatments are limited to tumors that are small (<3 cm diameter), exophytic, and away from vital structures such as ureter or intestine. Novel treatment approaches are geared towards increasing the size of the thermal lesion created, limiting damage to collateral normal tissues, reducing local recurrence and distant metastases as well as improving the imaging potential of the therapy. Previous studies have demonstrated the enhancement of thermal therapies in pre-clinical murine models of solid tumors by intravenously infusing 33 nm TNF-α and PEG coated gold nanoparticles (CYT-6091, Cytimmune Sciences Inc.) prior to ablation. This study investigates the enhancement of thermal ablation therapy by CYT-6091 in a translational animal model of renal tumors. New Zealand White rabbits (37 for radiofrequency ablation (RFA), 20 for cryoablation) had VX-2 tumors implanted into their bilateral kidneys. The tumors were allowed to grow for 14 days to a size of ∼1 cm. For RFA, the rabbits were split into 3 treatment groups of 10 rabbits each and a sham group of 7 rabbits. The groups were treated with CYT-6091 (200 μg/kg) only, RFA only, or CYT-6091 (200 μg/kg) followed 4 hours later by RFA. For cryoablation, 2 treatment groups of 10 rabbits each were used. The groups were treated with cryoablation only or CYT-6091 (200 μg/kg) followed 4 hours later by cryoablation. The kidneys were harvested 3 days later for RFA and 7 days later for cryoablation. Gross and microscopic measurements of the ablation size as well as histological analysis using H&E staining were performed. The RFA plus CYT-6091 group had a larger zone of complete cell death than the RFA only group when measured both on gross sectioning (0.32±0.03 vs. 0.22±0.07cm3, p=0.015) and on microscopic examination (0.30±0.07 vs. 0.23±0.03cm3, p=0.03). Overall this was a 23% increase in ablation volume. This difference in ablation size was due to a replacement of partially ablated tissue at the periphery in the RFA only group by completely ablated tissue in the RFA plus CYT-6091 group. Thus this zone of partially ablated tissue was smaller in the RFA plus CYT-6091 group than the RFA only group (0.08±0.02cm3 vs. 0.13±0.05cm3, p=0.01). Excessive tumor growth into the ablation lesion at day 7 following cryoablation prevented accurate measurements in these groups; however, a significant decrease in the rate of peritoneal carcinomatosis (metastases) was obtained in the cryo plus CYT-6091 group compared to the cryoablation alone group (1/10 vs. 8/10, p=0.04). We have shown that use of CYT-6091 prior to thermal ablation therapy in a rabbit kidney tumor model can minimize the zone of partial treatment at the periphery of the thermal lesion and thus maximize the complete kill zone in RFA while significantly decreasing the rate of metastases in cryoablation. These data provide preliminary evidence for the efficacy of adjuvant use of CYT-6091 for thermal ablation therapies in a large animal translational tumor model.

Mitigation approaches to combat the flu pandemic

Management of flu pandemic is a perpetual challenge for the medical fraternity since time immemorial. Animal to human transmission has been observed thrice in the last century within an average range of 11-39 years of antigenic recycling. The recent outbreak of influenza A (H1N1, also termed as swine flu), first reported in Mexico on April 26, 2009, occurred in the forty first year since last reported flu pandemic (July 1968). Within less than 50 days, it has assumed pandemic proportions (phase VI) affecting over 76 countries with 163 deaths/35,928 cases (as on 15(th) June 2009). It indicated the re-emergence of genetically reassorted virus having strains endemic to humans, swine and avian (H5N1). The World Health Organisation (WHO) member states have already pulled up their socks and geared up to combat such criticalities. Earlier outbreaks of avian flu (H5N1) in different countries led WHO to develop pandemic preparedness strategies with national/regional plans on pandemic preparedness. Numerous factors related to climatic conditions, socio-economic strata, governance and sharing of information/logistics at all levels have been considered critical indicators in monitoring the dynamics of escalation towards a pandemic situation.The National Disaster Management Authority (NDMA), Government of India, with the active cooperation of UN agencies and other stakeholders/experts has formulated a concept paper on role of nonhealth service providers during pandemics in April 2008 and released national guidelines - management of biological disasters in July 2008. These guidelines enumerate that the success of medical management endeavors like pharmaceutical (anti-viral Oseltamivir and Zanamivir therapies), nonpharmaceutical interventions and vaccination development etc., largely depends on level of resistance offered by mutagenic viral strain and rationale use of pharmaco therapeutic interventions. This article describes the mitigation approach to combat flu pandemic with its effective implementation at national, state and local levels.

Phase I study of the IXO regimen, irinotecan (I), capecitabine (X), oxaliplatin (O), as first-line therapy for metastatic colorectal cancer: Final survival results

4082

Background: This study was designed to determine the dose-limiting toxicity (DLT), maximum tolerated dose (MTD) and efficacy of the IXO regimen when used as first-line treatment for metastatic colorectal cancer (mCRC). Methods: Patients with ECOG PS 0–2, histologically proven, chemo-naïve, non-resectable mCRC were eligible. Phase I starting doses were as follows: I (180 mg/m2 i.v.) d1, X (850 mg/m2 bid orally) d2–15, O (85 mg/m2 i.v.) d1; q3w. Dose escalation (3+3 design) was based on toxicity observed at previous dose levels (DL) until DLT and the MTD were reached. Results: 39 pts (31 male/8 female, median age 58 years, ECOG PS 0–1 in 37, 95%) received a median of 11 cycles (range 1–34) at 8 DLs. 39 pts were evaluable for toxicity. The most common grade 3/4 hematological adverse events (AEs) were granulocytopenia (60%) and fever/febrile neutropenia (18%). The most common grade 3 non-hematological AEs were diarrhea (15%), vomiting (10%), fatigue (8%). No grade 3/4 neuropathy was reported. DLTs: 1 DLT was observed at each of the first 4 DLs, no DLTs at DL5 & 6, 1 at DL7 and 2 at DL8. MTD was reached at DL8. The recommended phase II dose (DL7) is as follows: I (160 mg/m2), X (950 mg/m2), O (100 mg/m2). Efficacy: 38 pts are evaluable for efficacy. The RR is 74% (95% CI 60–89), including 4 CRs, 25 PRs and 6 SDs. The disease control rate is 90% (95% CI 80–100). 10 (26%) pts had subsequent liver surgery with curative intent; 1 had lung resection. Median progression-free survival was 12.3 months (95% CI, 8–17). Overall median survival was 26.4 months (95% CI, 13–36). Conclusions: Diarrhea is the main DLT. Severe neutropenia was of short duration and manageable. The IXO regimen is well tolerated and highly effective as first-line treatment for mCRC. It appears to be particularly effective in downsizing of initially unresectable colorectal cancer liver metastases. A phase II study to confirm the efficacy/safety of IXO in combination with bevacizumab (Avastin) is ongoing. Supported by: Hoffmann La-Roche, Sanofi-Aventis, Pfizer Canada.

[Table: see text]

Phase I study of E7389/gemcitabine combination in patients with advanced solid tumors

e13509

Background: E7389 (E) is a synthetic analogue of halichondrin B, an investigational tubulin-based antimitotic drug. Gemcitabine (G) is a nucleoside analogue clinically active in several human tumours. These two drugs exhibit synergistic cytotoxic effects against the H522 non-small cell lung cancer (NSCLC) xenografts. Methods: A phase I study of these two drugs in combination was initiated in patients with advanced solid tumours. Two prior chemotherapy regimens for metastatic disease were allowed. Results: Patient characteristics: male 11/female 10; median age 59 (range 28–84); performance status 0 /1/2: n=1/13/7; prior chemotherapy 21, prior radiotherapy 7, prior immunotherapy 1; tumour types: ovarian cancer 3, endometrial cancer 3, NSCLC 3, gastric/esophageal adenocarcinoma 3, miscellaneous 9. Total number of cycles given 52, median cycles/patient (range) 2 (1, 8). Cohort (CT) 1: E/G given days 1,8,15 q28 days. Due to DLT, regimen changed in CT 2 with E/G given days 1, 8 q21 days. Cycles (C) given: median 2 range 1–8, total 52. Response: partial response 1 (ovarian cancer), stable 8 [minor response 4 (NSCLC 2, endometrial cancer 1, head and neck cancer 1)], progression 8, inevaluable 4. Conclusions: Further phase II investigation of this regimen should be considered at a dose of E 1.0 g/m2/G 1000 mg/m2 q 3 weeks.

[Table: see text]

No significant financial relationships to disclose.

CFD simulation of mixing in anaerobic digesters

A three-dimensional CFD model incorporating the rheological properties of sludge was developed and applied to quantify mixing in a full-scale anaerobic digester. The results of the model were found to be in good agreement with experimental tracer response curve. In order to predict the dynamics of mixing, a new parameter, UI (uniformity index) was defined. The visual patterns of tracer mixing in simulation were well reflected in the dynamic variation in the value of UI. The developed model and methods were applied to determine the required time for complete mixing in a full-scale digester at different solid concentrations. This information on mixing time is considered to be useful in optimizing the feeding cycles for better digester performance.

Canadian pattern of care for anemia: comparison of chemotherapies in adjuvant breast cancer setting

Abstract #2118

Background: Anemia is a common side effect of chemotherapy in adjuvant breast cancer patients (pts) but its treatment may be inconsistent. Erythropoiesis-stimulating agents (ESAs) are the only alternative to blood transfusion in the treatment of chemotherapy-induced anemia, yet their appropriate use continues to be defined. The purpose of this study was to determine the frequency of anemia associated with adjuvant chemotherapy in Canadian breast cancer pts and to explore the corrective interventions which were undertaken.&#x2028; Methods: A retrospective chart review was conducted at 11 cancer centres in Ontario, Canada. Beginning on September 1, 2004 data were collected for 60 consecutive cases of adjuvant breast cancer at each centre, giving a total of 620 patients. Chemotherapy consisted mainly of FEC100, AC-T, AC, CEF, FEC50, and AC-T Dose Dense. Overall, 8% of pts were enrolled in a clinical trial and 76% received adjuvant radiotherapy. Hemoglobin level (Hb), supportive therapy (antibiotics, GCSF, ESA, and transfusion) and type of chemotherapy were recorded at each cycle.&#x2028; Results: The median pt age was 53. The mean baseline Hb was 132.8 (92.0-163) g/L, 11.6% of pts had Hb&lt;120g/L. During the course of chemotherapy, the percentage of subjects with Hb&lt;120 at least once was 55.8%, Hb&lt;110 was 37.8%, Hb&lt;100 was 21.2 % and Hb&lt;90 was 11.5%, with a median of 36.0, 52.5, 71.0, and 75.0 days to develop anemia respectively. For pts whose Hb dropped below 100 g/L, 45.4% occurred after the 1st cycle, 68.8% after the 2nd, 83.7% after the 3rd, and 92.2% after the 4th chemotherapy cycle. Overall, 13.2% of subjects received prophylactic antibiotics, 26.3% were supported by G-CSF, 9.0% received an ESA (epoetin alfa) during their chemotherapy and 7.4% were transfused. The rates of anemia as well as means of intervention are summarized in Figure 1. ESAs were not used prophylactically in this setting.&#x2028; Conclusions: In Canada, breast cancer patients receiving adjuvant chemotherapy commonly become anemic during their course of treatment. This retrospective study demonstrated that ESAs play an important role in the management of anemia in the adjuvant setting. Canadian treatment guidelines recommend that ESA therapy be initiated when Hb &lt;100 g/L. Our finding shows that ∼42% of patients whose Hb dropped below 100g/L were treated with ESAs, suggesting that ESAs were not overused in Canadian practice.&#x2028; &#x2028;

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2118.

Valvular regurgitation and stenosis: when is surgery required?

Valvular heart disease is a growing public health problem, with an increasing prevalence due to an ageing population. Despite advances, the medical management of symptomatic valvular heart diseases remains suboptimal, necessitating surgical correction. The challenge remains in identifying an asymptomatic or mildly symptomatic patient who will benefit from timely surgery before irreversible changes in cardiac function have occurred. The potential risks of surgery versus watchful expectancy require careful decision-making. This review is a focused update on the existing guidelines and identifies the knowledge gaps and avenues of future research in the management of patients with valvular heart diseases.

Capecitabine plus oxaliplatin (XELOX) versus 5-fluorouracil/folinic acid plus oxaliplatin (FOLFOX-4) as second-line therapy in metastatic colorectal cancer: a randomized phase III noninferiority study

BACKGROUND

To demonstrate the noninferiority of capecitabine plus oxaliplatin (XELOX) versus 5-fluorouracil/folinic acid and oxaliplatin (FOLFOX-4) as second-line therapy in patients with metastatic colorectal cancer after prior irinotecan-based chemotherapy.

PATIENTS AND METHODS

A total of 627 patients were randomly assigned to receive XELOX (n = 313) or FOLFOX-4 (n = 314) following disease progression/recurrence or intolerance to irinotecan-based chemotherapy. The primary end point was progression-free survival (PFS).

RESULTS

PFS for XELOX was noninferior to FOLFOX-4 [hazard ratio (HR) = 0.97; 95% confidence interval (CI) 0.83-1.14] in the intention-to-treat (ITT) population. Median PFS was 4.7 months with XELOX versus 4.8 months with FOLFOX-4. The robustness of the primary analysis was supported by multivariate and subgroup analyses. Median overall survival in the ITT population was 11.9 months with XELOX versus 12.5 months with FOLFOX-4 (HR = 1.02; 95% CI 0.86-1.21). Treatment-related grade 3/4 adverse events occurred in 50% of XELOX- and 65% of FOLFOX-4-treated patients. Whereas grade 3/4 neutropenia (35% versus 5% with XELOX) and febrile neutropenia (4% versus < 1%) were more common with FOLFOX-4, grade 3/4 diarrhea (19% versus 5% with FOLFOX-4) and grade 3 hand-foot syndrome (4% versus < 1%) were more common with XELOX.

CONCLUSION

XELOX is noninferior to FOLFOX-4 when administered as second-line treatment in patients with metastatic colorectal cancer.

Evaluation of state variable interface between the Activated Sludge Models and Anaerobic Digestion Model no 1

For plant wide modelling of wastewater treatment, it is necessary to develop a suitable state variables interface for integrating state of the art models of ASM and ADM1. ADM1 currently describes such an interface, however, its suitability needs to be experimentally evaluated. In this study, we characterised activated sludge under aerobic and anaerobic conditions to obtain representative state variables for both models. ASM state variables of X(S), X(H) and X(I) (as obtained from aerobic tests) and ADM1 state variables of X(C) and X(I) (as obtained from anaerobic tests) were then correlated to assess the suitability of current interface. Based on the seven datasets of this study and seven datasets from literatures, it was found that in general ASM state variables were well correlated to the state variables of ADM1. The ADM1 state variable of X(C) could be correlated to the sum of state variables of X(S) and X(H), while X(I) in both the models showed direct correspondence. It was also observed that the degradation kinetics of X(C) under anaerobic condition could be better described by individual degradation kinetics of X(S) and X(H). Therefore, to establish a one to one correspondence between ASM and ADM1 state variables and better description of degradation kinetics in ADM1, replacing the composite variable of X(C) by the state variables of X(S) and X(H) is recommended.

Modified ADM1 structure for modelling municipal primary sludge hydrolysis

This study elaborates the rate-limiting steps of particle disintegration/hydrolysis of primary sludge using methane production rate (MPR) curves from multiple batch experiments. Anaerobic batch degradation of fresh primary sludge showed a complex MPR curve marked with two well-defined temporal peaks. The first immediate peak was associated with the degradation of relatively readily hydrolysable substrates, while the second delayed peak was associated with the degradation of large-sized particles. For simulating the second delayed peak, it was necessary to consider a more elaborate particle disintegration/hydrolysis model. Based on the anaerobic respirograms of 17 runs in four datasets and using a substrate characterisation approach similar to activated sludge models (ASMs), the primary sludge was classified into three biodegradable fractions having different kinetics. These are (1) a hydrolysable substrate (X(Settle-I)) showing a degradation typical to slowly biodegradable compounds, (2) a substrate fraction (X(Settle-II)) having a degradation similar to lysis of biomass fraction and (3) a substrate requiring disintegration before hydrolysis (X(Settle-III)) representing the large-sized particles in primary sludge. Based on these results, modifications in the model structure of anaerobic digestion model no. 1 (ADM1) are proposed to improve the modelling of primary sludge solid degradation in anaerobic digesters.

Encouraging results from a phase I study of capecitabine (X), irinotecan (I) and oxaliplatin (O) as first-line therapy in patients (pts) with metastatic colorectal cancer (MCRC)

4086

Background: First-line treatment with I, O and infusional 5-FU/Leucovorin (LV) triplets is associated with high response rates and long survival in MCRC. The oral fluoropyrimidine X is better tolerated and shows improved response rates vs. 5- FU/LV in MCRC. This dose-escalation study aims to establish dose-limiting toxicity (DLT), maximum tolerated dose (MTD) and recommended phase II doses (RPIID) of I, O and X and to evaluate efficacy and safety in first-line. Methods: Starting doses were: I (180mg/m2 i.v. d1), O (85mg/m2 i.v. d1), × (850mg/m2 bid orally d2–15). Dose escalations are based on toxicity observed at previous dose level (DL), until DLT, MTD and RPIID are reached. Results: We have enrolled 27 pts (21 men, 6 women), median age 59 years (range 25–74), at 6 DLs. ECOG PS was 0 or 1 in 25 pts, and 2 in 2 pts. Pts received a median of 10 cycles (range 1–23). All pts are evaluable for toxicity (24 for efficacy). Most common grade 3/4 hematological adverse events (AEs) during dose escalation: granulocytopenia (41%), anemia (7%), and thrombocytopenia (15%). Most common grade 3 non-hematological AEs: late-onset diarrhea (11%), fever (14%), and fatigue (4%). DLTs at each dose level: DL1 (1 febrile neutropenia with bowel perforation); DL2 (1 grade 3 diarrhea); DL3 (1 febrile neutropenia with grade 2 edema); DL4 (1 severe febrile neutropenia in cycles 2&3, pt deceased due to sepsis); no DLTs were reported at DL5 & 6. MTD has not yet been reached. Overall response rate is 79% (95% CI, 62–97%), including 2 CRs and 17 PRs (3 still unconfirmed). Disease control rate is 92%. Two pts had subsequent curative liver resection and 4 pts are under consideration for curative procedures. Median progression-free survival is 15 months (95% CI, 8–22). Conclusions: XIO is well tolerated and highly effective as first-line treatment for MCRC. Severe neutropenia was significant but of short duration and manageable; it is likely to be the main DLT. MTD has not yet been identified but is expected shortly. A phase II study to confirm the efficacy and safety of XIO, possibly in combination with targeted agents, will follow. Supported by Roche, Sanofi-Aventis, and Pfizer Canada.

No significant financial relationships to disclose.

Are doctors themselves responsible for delay in cancer management?

17027

Background: In developing countries poor results of cancer management are believed to be due to late presentation of patients because of poverty, illiteracy and lack of cancer awareness. But the scenario changed little despite regular cancer awareness campaigns in last few decades. Methods: 1,006 cancer patients were assessed for time of onset of symptoms, time of presentation to physician, time taken in diagnosis & initiation of anticancer treatment to identify the level of delay in cancer management and factors responsible. Results: 81.3% of the patients belonged to low socioeconomic group. 61.9% were illiterate & 43.7% were laborers. Literacy level of 84.5% of patients was under metric level and 50.3% had no awareness about cancer. 55.4% patients presented to qualified medical practitioners, 38.9% to non-qualified medical practitioners & 5.5% to qualified non-medical practitioners working as primary care physicians. Almost 80% of patients had delay in cancer management at various levels, the maximum being at diagnosis level. 67.3% patients presented to primary care physician within a month of onset of symptoms without delay. In 68.6% patients the diagnosis of cancer was delayed by more than one month once they presented, the physicians being responsible for this delay in 60.4 % cases. Though non-qualified physicians almost never diagnosed cancer but even 58% of the qualified medical physicians delayed the diagnosis of cancer in the symptomatic patients. In 77.1% patients, physicians did not suspect cancer and disposed off the patients on symptomatic treatment. Literacy of the patients affects awareness and has bearing on the pattern of consultation whereby most of the literates consulted qualified physicians while most of the illiterates consulted non-qualified physicians resulting in delay. Conclusions: Presentation of the cancer patient depends upon reaction to the symptom and therefore despite illiteracy and poverty, majority of symptomatic patients present without delay to their primary care physicians. Delay occurs at diagnosis level in most of the patients and physician is the most common factor responsible for this delay. Tendency to treat the symptoms rather than making diagnosis of the patient and poor oncology knowledge to differentiate symptoms of cancer may be the reasons for this.

No significant financial relationships to disclose.

Phase III trial of capecitabine + oxaliplatin (XELOX) vs. 5-fluorouracil (5-FU), leucovorin (LV), and oxaliplatin (FOLFOX4) as 2nd-line treatment for patients with metastatic colorectal cancer (MCRC)

4031

Background: Capecitabine is an oral fluoropyrimidine that has demonstrated similar efficacy to 5-FU/LV in the 1st-line treatment of MCRC. Most patients now receive multi-agent chemotherapy and FOLFOX4 has become a popular regimen in this setting. We conducted a phase III study comparing XELOX with FOLFOX4 in patients who had received prior treatment with irinotecan in combination with bolus and/or infusional 5-FU/LV for MCRC. The primary endpoint of the study was time-to-tumor progression (TTP). With 610 patients, this study had 80% power to detect non-inferiority of the XELOX vs. FOLFOX, defined by a progression hazard ratio (HR) of <1.3. Methods: Patients were treated with XELOX (oxaliplatin 130mg/m2 i.v., capecitabine 1,000mg/m2 bid oral x 14 days, q3w) or FOLFOX4 (as described previously). Results: The study recruited 627 patients (the intent-to-treat - ITT - group). Baseline characteristics were well balanced. The primary objective of the study was met with a progression HR of 0.97 for the XELOX group (95% CI, 0.83–1.14). Median TTP was 4.8 months for XELOX- and 4.7 months for FOLFOX4-treated patients. Overall survival was also similar between the groups with a death HR of 1.03 for the XELOX group (95% CI, 0.87–1.23). Median survival was 11.9 months for XELOX- and 12.6 months for FOLFOX4-treated patients. Grade 3/4 toxicities occurred in 60.1% of XELOX- and 72.4% of FOLFOX4-treated patients. The most common treatment-related grade 3/4 adverse events (XELOX vs. FOLFOX4) were: diarrhea (20 vs. 5%), neutropenia (5 vs. 35%), fatigue (5 vs. 8%), paresthesia (9 vs. 8%), nausea/vomiting (6 vs. 5%). The rate of grade 3 hand-foot syndrome was 3.5% with XELOX and 0.6% with FOLFOX4. The 60-day all cause mortality was 3.9% in XELOX- and 4.2% in FOLFOX4-treated patients. Conclusions: These results demonstrate that second-line treatment with XELOX is non-inferior to FOLFOX4 in terms of PFS. Results for overall survival and response rates were also similar between the two groups. The safety profile was similar to previous studies, with no unexpected toxicities. Study supported by Hoffmann-La Roche.

No significant financial relationships to disclose.

Management of Calculi in A Donor Kidney

INTRODUCTION

We evaluated the safety and efficacy of ex vivo ureteroscopy (ExURS) and extracorporeal shock wave lithotripsy (ESWL) as means of rendering a donated kidney stone-free in living related and deceased donor renal transplantation.

MATERIAL AND METHODS

Three cases with calculi in donor kidneys were managed; 1 was from a living related donor and 2 were from deceased donors. Immediately after cold perfusion, ExURS was performed with iced saline solution in 2 cases. Access to the collecting system was via the ureteral stump. Calculi were fragmented with pneumatic intracorporeal lithotripsy and fragments were removed with forceps. Posttransplantation ESWL was given to 1 patient for migration of a small lower caliceal calculus in the upper ureter in 1 allograft of a dual-kidney transplantation.

RESULTS

Access to the renal collecting system and stone fragmentation was technically successful in both cases. Indwelling ureteral stents were kept during transplantation in all cases. There were no intraoperative or postoperative ureteral complications. Following ESWL, stone was fragmented and cleared on its own within a week. At mean follow up of 2.2 years no new stone formed in any recipient or donor.

CONCLUSIONS

ExURS was technically feasible to render a stone-bearing kidney stone- free without compromising ureteral integrity or renal allograft function. ESWL could be performed at a later date.