Clinical and immunological assessment of Mycobacterium vaccae (SRL172) with chemotherapy in patients with malignant mesothelioma

The objectives of this study were to determine the toxicity of intratumoural/intrapleural SRL172 in addition to intradermal SRL172 and standard chemotherapy (mitomycin-C, vinblastine and cisplatin) in patients with malignant mesothelioma. Patients received chemotherapy (mitomycin-C: 8 mg m(-2), vinblastine: 6 mg m(-2), cisplatin 50 mg m(-2)) on a 3-weekly basis for up to six courses. IP SRL172 injections were given 3-weekly prior to chemotherapy and escalated in groups of three patients from 1 microg to 1 mg bacilli in 10-fold increments. Patients were also given ID SRL172 at a dose of 1 mg bacilli 4-weekly. Patients were assessed for toxicity after each course of chemotherapy and for response by CT imaging. Immuno-haematological parameters were analyzed pre-treatment and 1 month after completion of treatment. There was no dose limiting toxicity with IP SRL172 although there was greater toxicity at the highest dose (n=13). There were six out of 16 partial responses (37.5%). Haemato-immunological parameters, measured in seven patients pre and post-therapy, revealed that response rate correlated with a decrease in platelet count and there was an increase in activation of natural killer cells and a decrease in the percentage of IL-4 producing T cells in all tested patients post-treatment. SRL172 can be given safely into tumour deposits and the pleural cavity in patients with malignant mesothelioma and we have established the dose for phase II testing.

Stereotactic radiotherapy for solitary brain metastases

PURPOSE

Surgery is considered to be the treatment of choice for patients with solitary brain metastases. We report a single-centre experience of stereotactic radiotherapy (SRT)/radiosurgery as an alternative to surgery and define prognostic parameters that provide for a more rational selection of patients for appropriate treatment.

PATIENTS AND METHODS

Between 1990 and 1997, 96 patients with 106 brain metastases received SRT to a dose of 20 Gy in two fractions (range 20-30 Gy in 24 fractions) either alone or in combination with whole brain radiotherapy.

RESULTS

After SRT, 51% of patients had improvement in neurological function. The median survival of the 96 patients was 9 months. The Radiation Therapy Oncology Group prognostic grouping for patients with multiple brain metastases (prognostic factors: age, performance status, systemic metastases, status of primary tumour) was applicable to this cohort, with median survivals of 15, 8 and 2 months for favourable, intermediate and poor prognostic groups respectively.

CONCLUSION

SRT is a non-invasive method of treatment of solitary brain metastases and the outcome is comparable with the results obtained after surgical excision. Prognosis is determined by factors defined for patients with multiple brain metastases, with performance status being the most important. SRT/radiosurgery should be reserved for patients with favourable prognostic factors, with a Karnofsky performance status >70, who have a reasonable chance of good quality prolonged survival. In future trials, radiosurgery should be compared in terms of survival, quality of life and health economics to whole brain radiotherapy and surgery.

Randomized prospective study comparing preoperative epidural and intraoperative perineural analgesia for the prevention of postoperative stump and phantom limb pain following major amputation

BACKGROUND AND OBJECTIVES

Acute stump pain and phantom limb pain after amputation is a significant problem among amputees with a reported incidence of phantom limb pain in the first year following amputation as high as 70%. Epidural analgesia before limb amputation is commonly used to reduce postamputation acute stump pain in the immediate postoperative period and phantom pain in the first year. We investigated whether immediate postamputation stump pain and phantom pain in the first year is reduced by preoperative epidural block with bupivacaine and diamorphine compared with intraoperative placement of a perineural catheter infusing bupivacaine.

METHODS

In a randomized prospective trial, 30 patients scheduled for lower limb amputation were randomly assigned epidural bupivacaine at the standard rate used in our hospital (0.166%, 2 to 8 mL/h) and diamorphine (0.2 to 0.8 mg/h) for 24 hours before and during operation (14 patients; epidural group) and 3 days postoperatively, or an intraoperatively placed perineural catheter (16 patients; perineural group) for intra and postoperative administration of bupivacaine (0.25%, 10 mL/h). All patients had general anesthesia for the amputation and were asked about stump and phantom pain in the first 3 days and then at 6 and 12 months by an independent examiner. Study endpoints were rate of stump and phantom pain, intensity of stump and phantom pain, and consumption of opioids. The groups were well matched in baseline characteristics.

RESULTS

Stump pain scores in the first 3 days were significantly higher in the perineural group compared with the epidural group (P <.01). After 3 days, 4 (29%) patients in the epidural group and 7 (44%) in the perineural group had phantom pain (P =.32). Numbers of patients with phantom pain for epidural versus perineural group were: 5 (63%) versus 7 (88%) (P =.25) at 6 months; 3 (38%) versus 4 (50%) (P =.61) at 12 months. Stump pain and phantom sensation were similar in both groups at 6 and 12 months.

CONCLUSIONS

Using our regimen, perioperative epidural block started 24 hours before the amputation is not superior to infusion of local anaesthetic via a perineural catheter in preventing phantom pain, but gives better relief of stump pain in the immediate postoperative period.

Use of first line bronchoalveolar lavage in the immunosuppressed oncology patient

Immunosuppressed oncology patients who develop pulmonary infiltrates during treatment have a mortality rate of the order of 55-90%. Early diagnosis and treatment is associated with increased survival. At present, diagnosis relies on invasive sampling of the respiratory tract using fibre-optic bronchoscopy. We have looked at a 30-month period, from June 1997 to December 1999, where 25 bronchoscopies were performed on patients from the Lymphoma and BMT units at The Royal Marsden Hospital for the further investigation of pulmonary infiltrates. Nine bronchoscopies (36%) yielded a positive result and seven (28%) led to a change in management. Analysis of the data showed that neither a positive result nor a change in management had any impact on overall survival. After reviewing the background literature on the investigation of pulmonary infiltrates in this group and discussion of the respective merits and limitations, we propose a management flowchart, with high-resolution computed tomography (HRCT) as the test arm in a future randomised trial of these patients.

Predicting axillary lymph node metastases in patients with T1infiltrating ductal carcinoma of the breast

Factors which can predict an increased risk of axillary metastases in cases of T1 breast cancer could help to identify those patients most likely to benefit from axillary surgery. This pragmatic study aimed to examine the ability of commonly reported tumour pathological features to predict axillary metastases. All cases of T1 infiltrating ductal carcinoma excised with ipsilateral axillary nodes over a 7 year period were reviewed retrospectively. Of the 639 cases, 197 (30.8%) had positive nodes. Axillary metastases were found with 66.3% of tumours showing vascular invasion but only 16.0% of those without vascular invasion. Following multivariate analysis, vascular invasion and tumour size were found to be independent predictors of positive nodes but tumour grade was not. The decision to perform axillary dissection in T1 breast cancer could be based on the presence of vascular invasion and the size of the primary tumour.

Duration of chemotherapy in advanced non-small-cell lung cancer: a randomized trial of three versus six courses of mitomycin, vinblastine, and cisplatin

PURPOSE

So far there are no published data on optimal duration of chemotherapy for advanced non-small-cell lung cancer (NSCLC); six or more courses are usually recommended. We have carried out a multicenter randomized trial comparing three versus six courses of chemotherapy.

PATIENTS AND METHODS

Patients with stage IIIb or IV NSCLC were randomized at start of treatment to receive either three or six courses of mitomycin 8 mg/m(2) (courses 1, 2, 4, and 6), vinblastine 6 mg/m(2), and cisplatin 50 mg/m(2) (MVP) every 21 days. Treatment was stopped early in both arms for progressive disease or unacceptable toxicity. Key end points were overall survival, duration of symptom relief, and quality-of-life assessment using the European Organization for Research and Treatment of Cancer (EORTC) core questionnaire QLQ-C30 with lung cancer-specific module QLQ-LC13.

RESULTS

Three hundred eight patients were randomized. Seventy-two percent of the 155 patients randomized to three courses completed treatment. In the 153 patients randomized to six courses, 73% completed three courses and 31% six courses. Median survival was 6 versus 7 months, respectively, and 1-year survival 22% versus 25% (P =.2). Median duration of symptom relief was 4.5 months (both arms), and 8% versus 18% had continuing symptom relief (P =.4). Quality-of-life parameters were the same or improved for patients randomized to only three courses, including significantly decreased fatigue (P =.03) and a trend toward decreased nausea and vomiting (P =.06).

CONCLUSION

Our findings show no evidence for additional clinical benefit by continuing MVP chemotherapy beyond three courses. This challenges current orthodoxy of six courses or more. Further trials addressing duration of chemotherapy are now warranted, particularly with newer chemotherapy schedules.

Serum p53 antibodies: predictors of survival in small-cell lung cancer?

Serum p53 antibodies have been shown to be a poor prognostic marker in resected non-small-cell lung cancer (NSCLC), but studies in small-cell lung cancer (SCLC) have been contradictory. We have studied the incidence of p53 antibodies in a large SCLC cohort treated at one oncology centre and correlated the results with survival. 231 patients (63% male, median age 65), diagnosed and treated for SCLC between 1987 and 1994 at The Royal Marsden Hospital NHS Trust, had sera stored pretreatment. All samples were tested for p53 antibodies (p53-Ab) using a standardized ELISA technique with a selection of strongly ELISA positive, weakly ELISA positive and negative samples being confirmed with immunoprecipitation. 54 patients were positive for p53-Ab (23%). The presence of a high titre of p53-Ab (titre ratio >5) appears to be associated with a survival advantage with a relative risk of death of 1.71 (95% CI: 1.14-2.58) in those without the antibody (P = 0.02). This study, the largest homogeneous group so far looking at p53-Ab in SCLC, suggests that p53 antibody detection may have a role in predicting outcome in this type of cancer.

Short-term results of femoropopliteal subintimal angioplasty

BACKGROUND

Subintimal angioplasty may be more successful than conventional (intraluminal) angioplasty for treatment of long femoropopliteal occlusions. This study assessed the clinical and haemodynamic outcome of subintimal angioplasty.

METHODS

All patients with femoropopliteal occlusions treated by subintimal angioplasty over a 3-year period at two centres were reviewed. Clinical assessment and colour duplex imaging were carried out.

RESULTS

Sixty-nine procedures were performed in 33 men and 33 women of median age 74 (range 47-92) years. Indications for treatment were intermittent claudication in 26 (38 per cent) and critical limb ischaemia in 43 (62 per cent). Median occlusion length was 10 (range 2-50) cm. Primary technical success was achieved in 51 occlusions (74 per cent). There were 11 complications (16 per cent); the majority were minor but surgical intervention was required in two patients (3 per cent). At 6 months the cumulative symptomatic and haemodynamic primary patency rates were 60 and 51 per cent respectively, analysed on an intention-to-treat basis. The symptomatic and haemodynamic patency rates for technically successful procedures were 80 and 77 per cent respectively.

CONCLUSION

In this series the short-term clinical success of subintimal angioplasty was poor because of a high incidence of reocclusion and restenosis, despite a relatively high initial technical success rate.

Multimodality therapy in inflammatory breast cancer: is there a place for surgery?

BACKGROUND

In many centres surgery is used as part of a combined modality approach to the treatment of inflammatory breast cancer (IBC). Nevertheless, its value is controversial given the high risk of metastatic relapse and poor overall prognosis. We have reviewed patients with true IBC prospectively treated at the Royal Marsden Hospital in chemotherapy trials to assess further the role of surgery as part of combined modality treatment.

PATIENTS AND METHODS

Fifty-four patients who had responsive or stable disease to primary chemotherapy went on to have either radiotherapy alone (n = 35) or surgery plus radiotherapy (n = 19); the decision on surgery was based partly on clinician preference and partly on clinical response.

RESULTS

The 35 patients undergoing radiotherapy alone had a median progression-free survival (PFS) of 16 months and median overall survival (OS) of 35 months. Twenty-four patients (69%) have relapsed with a total of twelve (34%) relapsing locally. In comparison, the 19 patients receiving both surgery and radiotherapy had a PFS of 20 months, and a median OS of 35 months. Fifteen patients (79%) have relapsed, eight (42%) of these locally. None of these differences were statistically significant.

CONCLUSIONS

These results do not suggest a clinical advantage for surgery in addition to chemotherapy and radiotherapy for patients with IBC. They support the need for a prospective randomised trial to address this question.

Tourniquets in arterial bypass surgery

BACKGROUND

successful infra-popliteal bypass depends on precise, atraumatic technique in performing the distal anastomosis. The use of a tourniquet facilitates the distal anastomosis, reducing dissection, avoiding traumatising clamping of the vessels and providing an "uncluttered" operating field. Despite these advantages the technique is under-used.

OBJECTIVES

to review the use of tourniquets in arterial reconstruction, with particular reference to safety issues and complications. DESIGN, METHODS AND MATERIALS: a Medline search was performed (last search Feb. 2000), and keywords from relevant papers were used to perform subsequent searches. References were reviewed from each relevant paper.

RESULTS

no randomised controlled trials were found. The review details reported use of tourniquets in arterial reconstruction, including techniques, outcomes and potential complications.

CONCLUSION

the use of a tourniquet is a safe and effective technique to facilitate arterial reconstruction.

Secondary myelodysplastic syndrome/acute myeloid leukaemia following mitoxantrone-based therapy for breast carcinoma

Of 1774 patients with breast cancer given mitoxantrone (MTZ) with methotrexate (n = 492) or with methotrexate and mitomycin C (n = 1282), nine developed MDS/AML after a median of 2.5 years. Median duration of survival from diagnosis of MDS/AML was 10 months and six patients died. The crude incidence of developing MDS/AML after MMM or MM chemotherapy was 15 per 100,000 patient years follow-up, while the actuarial risk was 1.1% and 1.6% at 5 and 10 years respectively. MTZ-based regimens carry a 10 x higher risk of subsequent MDS/AML compared to that seen in the general population.

Continuous infusional combination chemotherapy in inflammatory breast cancer: a phase II study

Despite the introduction of systemic chemotherapy, inflammatory breast cancer (IBC) remains a disease with a poor prognosis. We performed this phase II study to evaluate the efficacy of infusional chemotherapy as initial treatment in patients with IBC. Fifty-four patients with newly diagnosed IBC were offered infusional chemotherapy and 34 accepted. The schedule consisted of continuous infusional ECF (bolus epirubicin and cisplatin, substituted by carboplatin or cyclophosphamide in some patients) plus continuous 5-FU, given three weekly for six cycles. Following chemotherapy patients went on to have surgery and/or radiotherapy. The chemotherapy was well tolerated and resulted in an overall response rate of 79% with 35% of patients achieving a complete clinical response. The median response duration, time to progression and overall survival were 12 months (4-89+ months), 12 months (4-89+ months) and 23 months (7-89+ months), respectively. Patients had a 5 year disease free and overall survival of 11% and 29%, respectively. Infusional ECF is well tolerated and achieves a high clinical response rate in patients with IBC, but survival results do not appear to be superior to those achieved with conventional bolus chemotherapy schedules.

Evaluation of a nurse-led telephone clinic in the follow-up of patients with malignant glioma

The aim of this study was to evaluate nurse-led telephone follow-up (NTF) for patients with high-grade glioma as an alternative to conventional clinic follow-up (CCF) and to assess patient satisfaction with this approach. Patients who were completing primary therapy for high-grade glioma and were suitable for CCF were offered the alternative of nurse-led telephone follow-up. NTF was arranged by the nurse at mutually agreed times. Assessment was by open discussion and a semistructured questionnaire, together with the Barthel Activities of Daily Living Index. Formal medical assessment in the clinic was arranged at 4-month intervals or earlier if indicated. Twenty-two patients were asked to complete a satisfaction questionnaire. Between February 1996 and October 1997, 43 patients with high-grade glioma, one with primitive neuroectodermal tumour and one with oligoastrocytoma agreed to be monitored by NTF. Their median survival from diagnosis was 16 months (95% confidence interval 13-23 months). At the time of analysis, the median time of follow-up by the telephone clinic was 6 months (range 2-21), with symptomatic progressive disease the reason for discontinuation of NTF in all patients. Two-hundred and fifty-four telephone calls were made, of which 234 were routine and 20 non-routine, being initiated by the patients or their carers. NTF was considered as a sufficient replacement for CCF during the stable phase of the disease. There were 41 unscheduled clinic visits, of which 31 were at the time of progression and usually initiated at NTF. The majority of unplanned visits were due to a change in symptoms and would not have been avoided with CCF carried out at the same time intervals. Patient satisfaction was high, with a median satisfaction score of 9, (range 3.6-10 ) on a scale of 0-10. NTF provides an alternative approach to conventional hospital attendance and moves the emphasis away from cancer surveillance to a more patient centred supportive model. It can be carried out without apparent detriment to the patient and is associated with high satisfaction rating.