Toxicity of concurrent radiotherapy with CMF chemotherapy in the E-CMF adjuvant breast carcinoma regimen

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Background: In the adjuvant management of breast cancer although delivery of radiotherapy (RT) concurrently with anthracyclines is contraindicated, toxicities are acceptable when the chemotherapy regimen used is CMF. The NEAT trial (NEJM 2006; 355:1851- 1862), presented at ASCO in 2003 demonstrated a significant survival advantage for sequential 4x epirubicin and 4x CMF chemotherapy (E- CMF) compared with 6x CMF and was adopted in the UK as a standard regimen. In order to limit treatment duration, RT may be given concurrently with chemotherapy during the CMF phase of treatment. We have reviewed the toxicity associated with this approach. Methods: Retrospective review of all patients treated with concurrent breast RT and CMF chemotherapy as part of the E-CMF regimen in our institution. Toxicities were graded according to the Radiation Therapy Oncology Group (RTOG) toxicity criteria. Confidence intervals were calculated by the binomial method using Stata version 9. Results: 77 patients received concurrent therapy between March 2004 and May 2006. Baseline characteristics; median age: 48, ER positive: 63.5%, HER2 positive: 11.7%, node positive disease: 85.7%. Type of surgery; lumpectomy: 61.0%, mastectomy: 39.0%, nodal dissection: 100%. Chemotherapy delivery; completed without delay: 35.1%, completed therapy with dose reduction/delay: 48.1%, discontinued therapy prematurely due to toxicity 16.8%. Sites of RT; breast: 62.3%, chest wall: 35.1%, axillary nodes: 45.5%, supraclavicular fossa: 36.4%. Schedule of RT; 50Gy/25#: 18.2%, 46/45Gy/20#: 67.6%, 45Gy/15#: 14.3%. Median interval between final dose of epirubicin and start of RT: 55 days. Toxicity; cutaneous grade 3–4 acute radiotherapy toxicity: 31.2% (95%CI 21.1–42.7%); cutaneous infective cellulitis: 14.3% (95%CI 7.4–21.1%); grade 3–4 neutropenia: 54.4% (95%CI 42.8–65.9%); febrile neutropenia requiring hospitalisation: 22.1% (95% CI 13.4–33.0%). The median duration of stay in hospitalised patients was 8 days (range 3–23 days). Conclusions: Toxicities were significantly greater than documented previously for concurrent therapy. RT should not be given concurrently with CMF chemotherapy as part of the E-CMF regimen.

No significant financial relationships to disclose.

HER2-positive breast cancer brain metastases: multiple responses to systemic chemotherapy and trastuzumab--a case report

Brain metastases from metastatic breast cancer typically occur in 10-15% of patients and are associated with survival of 3-6 months. Recent series have shown that women with HER2-positive metastatic breast cancer receiving the drug trastuzumab develop brain metastases more frequently than this, but also that continuation of trastuzumab after diagnosis of brain metastases in such patients is associated with extended survival. Authors have speculated that this is due to improved systemic control of disease; however, a possibility is that trastuzumab may have a beneficial effect on cerebral metastases themselves. We report the case of a woman with HER2-positive metastatic breast cancer who developed multiple brain metastases while on trastuzumab, in whom the addition of systemic chemotherapy to continued trastuzumab has produced multiple treatment responses associated with prolonged survival. This is the first report of its kind.

Chemoradiotherapy in multicentric glioblastoma multiforme—A clinical study

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Background: Glioblastoma multiforme constitutes 40% of primary brain tumors. Multicentric Glioblastoma multiforme is rare about 3%.No definite guidelines is available in literature for management of these tumors. Methods: All Multicentric Glioblastoma multiforme were analyzed retrospectively from Jan 2003 to July 2005 for clinical behavior and response to chemoradiotharpy. Either Temozolamide or Carboplatin or Paclitaxel is used concurrently with radiation. Radiation dose 60 Gy/30 fractions over 6 weeks by bilateral parallel opposed fields was delivered using Cobalt-60 machine. Results: 27 cases were found, Male: Female 24:3, KPS 60 [40–70], Majority of them are symptomatic for 4 months, main symptoms were seizures, headache, vomiting, neurological deficite. 89% of them underwent one form of other surgical intervention. 11% were diagnosed on basis of radiological findings. 85% were supratentorial, 15% were both supra and infratentorial, one of which had spinal cord lesion. 6 [22%] patients did not receive any treatment. Among 21 patients 4 were treated only with radiotherapy, 17 with concurrent Chemoradiotherapy [Paclitaxel-8, Temozolamide-7 and Carboplatin-2]. 5 patients did not complete treatment. Among 16 patients only 6 came for first follow up, 5 of were concurrent Chemoradiotherapy [Temozolamide-4, Paclitaxel-l and RT alone 1]. At the end of 3 months only 2 patients with Temozolamide were alive. Conclusions: Multicentric Glioblastoma multiforme is an aggressive disease. Concurrent Chemoradiotherapy with Temozolamide has better role.

No significant financial relationships to disclose.

Micronuclei evaluation of reduction in neoadjuvant chemotherapy related acute toxicity in locally advanced lung cancer: an indian experience

BACKGROUND

Lung cancer is the most common cancer in the world accounting for 17.6% cancers worldwide. The AAR i n I ndian population varies f r om 0.98-15.55. The aim of t he present study was to analyze areduction in neoadjuvant chemotherapy related acute toxicity in locally advanced lung cancer (stage IIIA and III B) using Wobe Mugos E and its evaluation using micronuclei as a cytogenetic marker. Micronuclei, which are cytoplasmic fragments of DNA, have been used as a biological dosimeter to assess DNA damage.

MATERIAL AND METHODS

Fourty patients of locally advanced NSCLC were randomized into two study groups between 2001-2003. One group received neoadjuvant chemotherapy using Cisplatin and Etoposide. The other group received neoadjuvant chemotherapy using Cisplatin and Etoposide along with Wobe Mugos E which is a proteolytic enzyme preparation. A study of micronuclei frequency was done pre and post chemotherapy in both groups.

RESULTS

Thirty eight patients were available for final evaluation. Anemia was the most common hematological toxicity observed. Nausea and vomiting were the most common non -hematological toxicity seen. Wobe Mugos E was found to reduce the incidence of leucopenia (p = 0.005), nausea (p=0.004), vomiting (p= 0.003), sensory neuropathy (p = 0.032) and treatment related depression (p= 0.005). A reduction in micronuclei was seen in patients in patients on Wobe Mugos E. (p =0.01).

CONCLUSION

Neo-adjuvant chemotherapy related acute toxicity is a major problem in patients with advanced lung cancer. A reduction in micronuclei frequency shows Wobe Mugos E to be effective in reducing chemotherapy related acute toxicity.

Purified beta-glucan as an abiotic feed additive up-regulates the innate immune response in immature chickens against Salmonella enterica serovar Enteritidis

Functionally, the innate immune system of immature chickens is inefficient during the first week posthatch. This immunological inefficiency enables pathogens such as Salmonella enterica serovar Enteritidis (SE) to invade and colonize the visceral organs of immature chickens. The objective of this study was to evaluate the effect of purified beta-glucan as an immunomodulator of the innate immune response. beta-glucan, as a feed additive, significantly provided protection against SE organ invasion in young chickens (P<0.05). The functional efficiency of heterophils isolated from neonatal chickens fed a beta-glucan ration was significantly (P<0.05) up-regulated when compared to heterophils isolated from chickens fed a control ration as determined with an array of functional assays. Phagocytosis, bactericidal killing, and oxidative burst were significantly increased in heterophils isolated from chickens fed the purified beta-glucan ration (P<0.05). To our knowledge, this is the first report of a purified beta-glucan feed additive significantly decreasing the incidence of SE organ invasion in immature chickens and up-regulating the functional abilities of heterophils isolated from immature chickens against an invading pathogen, SE.

MANAGEMENT OF KALA AZAR - AN UPDATE

Kala azar continues to be a medical problem in India and with the increase in incidence of HIV Infection it is likely that kala azar will be encountered more frequently and in its atypical forms. To aid diagnosis, several immunological tests are now available and they are more sensitive and specific than the aldehyde test. Like many other diseases today, the treatment of kala azar is hampered by drug resistance. Newer drugs are available and so are new delivery systems. Kala azar develops frequently in the HIV infected person before development of AIDS. The presentation is atypical and leishmanial species other than L. donovani may also be the infecting agents. A combination of sandfly control, detection and treatment of patients and prevention of drug resistance continues to the ideal approach for the control of the disease.

Air pollutant stress changes the steady-state transcript levels of three photosynthesis genes

Six-week-old tobacco plants (Nicotiana tabacum L., cv. SR-1) were fumigated with different, but defined and realistic combinations of NO(2), automobile exhaust and ozone for two days. To determine the effect of an additional environmental stress during exposure, plants were either wounded mechanically or treated with salicylic acid to simulate pathogen attack. The steady-state mRNA levels of genes encoding the small subunit of ribulose-1,5-bisphosphate carboxylase/oxygenase (rbcS), chlorophyll a/b-binding protein (cab) and a 10 kDa protein of the water-evolving complex of photosystem II (ST-LS1) were probed in Northern analysis. Our results clearly show a decline of the mRNA levels for all three photosynthesis genes under automobile exhaust and/or ozone fumigation. Wounding and also elicitor treatment enhance this effect. In contrast, exposure to NO(2) either increased the transcription level of all three genes, or counteracted the negative effect of automobile exhaust and ozone on their expression. At this time no major changes in the concentrations of the corresponding proteins could be detected by Western blot analyses. These results are discussed in the present paper.

Transcriptional activation of plant defence genes by short-term air pollutant stress

The expression of defence genes was monitored by RNA blot analyses in tobacco plants (Nicotiana tabacum cv. SR-1) treated with various air pollutants at realistic concentrations that prevail in urban areas. Six-week-old plants responded with an increase in the steady-state mRNA levels of phenylalanine ammonia-lyase (PAL), chalcone synthase (CHS), chitinase and beta-1,3-glucanase, when exposed to defined and subnecrotic concentrations of automobile exhaust and/or ozone over a period of 48 h. An enhanced expression of genes encoding mitochondrial and cytosolic superoxide dismutases suggested that air pollutants induced considerable oxidative stress. Moreover, wounding or elicitor treatment of plants already exposed to automobile exhaust and/or ozone additionally increased the expression of the above defence genes, but not so in NO(2). Since the main difference between NO(2) and exhaust gas is the absence of the hydrocarbon compounds in the former, we regard hydrocarbons as favourite candidates for the toxic effect of exhaust gas, and they possibly act by generating an enhanced oxidative stress.