Prognostic significance of immunohistochemical micrometastases in node negative gastric cancer patients

BACKGROUND AND OBJECTIVES

The purpose of this study is to examine the prognostic significance of immunohistochemical (IHC) evidence of lymph node (LN) metastases in histologic node negative gastric cancer patients.

METHODS

Retrospective review from 1981 to 1998 revealed 25 patients resected for T1-4N0M0 gastric and gastroesophageal (GE) junction adenocarcinoma. All cases were reviewed and histopathologic parameters were defined for each primary tumor. All LNs underwent IHC analysis with the epithelial marker CAM 5.2. Data are reported as median (range).

RESULTS

The median number of LN resected was 7 (range 1-33). The median follow-up time was 25 months (range 4-195) with an overall 5-year survival rate of 55%. For patients with IHC evidence of LN micrometastasis (n = 9), the 5-year survival rate was significantly decreased (35%) compared to a 66% 5-year survival rate for IHC negative patients (n = 16, P = 0.05).

CONCLUSIONS

The presence of IHC-detected LN micrometastases correlates with worse prognosis for patients with histologic node negative gastric cancer. IHC may be a useful additional staging modality in this subset of patients.

Factors affecting the severity of motor vehicle traffic crashes involving elderly drivers in Ontario

A population-based cross-sectional study was conducted to examine factors affecting the severity of motor vehicle traffic crashes (MVTCs) involving elderly drivers in Ontario. The study population included drivers aged 65 and over involved in injury-producing MVTCs between 1988 and 1993 on Ontario public roads. Information was obtained from the Canadian Traffic Accident Information Databank (TRAID) compiled from police reports. The severity of MVTC was classified as fatal, major, minor or minimal. Comparisons between fatal-, major-, minor- and minimal-injury crashes were conducted. Percentage distributions of crashes at each level of severity involving elderly drivers were examined according to specific factors and tested using the X2 test. Multivariate unconditional logistic regression was used to calculate the estimated relative risk as odds ratios (ORs) while controlling for confounding factors. A number of factors were significantly related to the increased risk of fatal-injury in crashes compared with a reference category for each variable. These included age (OR = 1.4 for 70-79 and OR = 2.3 for 80 + ), sex (OR = 1.4 for males), failing to yield right-of-way/disobeying traffic signs (OR = 1.7), non-use of seat belts (OR = 4.0), ejection from vehicle (OR = 11.3), intersection without traffic controls (OR = 1.7), roads with higher speed limits (OR = 7.9 for 70-90 km/h; OR= 5.8 for 100 km/h), snowy weather (OR= 1.6), head-on collisions (OR=55.1), two-vehicle turning collisions (OR = 3.1 for left-turn, OR = 8.7 for right-turn), overtaking (OR = 5.6), and changing lanes (OR = 2.1). Adverse medical/physical conditions increased the risk of fatality by a factor of 5 for drivers 75-79 years of age and a factor of 3.5 for those 80 years and over. However, in the age group 65-74, medical/physical condition did not appear to be related to risk of fatality. Similar but weaker associations between these factors and risk of major- and minor-injury in crashes were also observed. To reduce the severity of crashes involving elderly drivers, strategies could target specific factors such as head-on collisions, single-vehicle collisions, and traffic controls at intersections. Driver conditions such as medical/physical conditions and driver actions such as failing to yield right-of-way/disobeying traffic signs should be examined further.

Clinical applications of the holmium:YAG laser in disorders of the paediatric airway

OBJECTIVE

The aim of this study was to review the role of the holmium:YAG laser in the management of paediatric airway disorders.

METHOD

Twenty-six paediatric patients underwent 42 airway procedures between June 1993 and August 1996 in a tertiary care centre. A case series design was used.

OUTCOME MEASURES

Safety, precision, hemostasis, bone-cutting properties, and accessibility of the lesion to the equipment were compared to standard therapies. Postoperative outcomes were then compared to standard therapies.

RESULTS

Eight patients underwent correction of choanal atresia or revision, 10 patients underwent functional endoscopic sinus surgery, 3 underwent excision of tracheal granuloma, 2 underwent excision of tracheal web or revisions, 1 underwent excision of subglottic stenosis and bronchial stenosis, 1 underwent excision hemangioma of the tongue, and 1 underwent excision papilloma of the oral cavity. One patient in 42 procedures suffered a surgical complication. Our early success rates are comparable to other series using the carbon dioxide laser or cold instruments.

CONCLUSION

The holmium:YAG laser is a safe, effective tool in the treatment of paediatric airway disorders and offers the advantage of a flexible fibre-optic system, good hemostasis, and better bone-cutting characteristics compared to the carbon dioxide laser, which is in widespread clinical use.

Decreased myocardial nNOS, increased iNOS and abnormal ECGs in mouse models of Duchenne muscular dystrophy

Duchenne muscular dystrophy is a devastating neuromuscular disease caused by lack of the protein, dystrophin, in skeletal muscle and heart, although the biochemical mechanism by which dystrophin loss causes muscle dysfunction is unknown. Here we show that the dystrophin-deficient mdx mouse and a mouse lacking both dystrophin and the dystrophin-related protein, utrophin (dko), have abnormal electrocardiograms (ECGs). In skeletal muscle, dystrophin is normally associated with neuronal nitric oxide synthase (nNOS) at the sarcolemma. Consequently, we have measured NOS isoform activities in hearts from control, mdx and dko mice. In control mouse hearts, eNOS and nNOS activities increased by 120% and 47%, respectively, between 2 and 6 months of age. In mdx mice, myocardial nNOS activity was decreased by 60%, 84% and 80% at 2, 6 and 12 months of age, respectively. Similarly, hearts from dko mice showed a 65% decrease in nNOS activity compared to controls at 2 months of age. Endothelial NOS (eNOS) activity was not affected by dystrophin loss, but inducible NOS (iNOS) activity was seven-fold higher than control in the mdx mouse heart by 12 months of age. We conclude that lack of dystrophin in the mdx mouse results in abnormal ECGs that are associated with decreased myocardial nNOS and increased iNOS activities.

Ovarian cancer histology-specific incidence trends in Canada 1969-1993: age-period-cohort analyses

This study examined histology-specific incidence trends of ovarian cancer in Canada, 1969-1993. The impact of age, period and cohort effects on these trends were studied by means of age-period-cohort analysis. Age-standardized incidence rates of serous, endometrioid, clear cell and germ cell tumours increased significantly and the rates of sex cord-stromal and other classified epithelial ovarian tumours decreased considerably. The rates of mucinous and NOS/unclassified tumours remained unchanged. Cohort effect has a major impact on incidence trends of serous, endometrioid, germ cell, sex cord-stromal and other classified epithelial ovarian tumours but no meaningful impact on trends of mucinous, clear cell, or NOS/unclassified ovarian tumours. Various cohort patterns by histology subtypes were observed: the risk of developing serious tumours increased markedly among birth cohorts of 1895-1930, stabilized thereafter and decreased among young cohorts of 1950-1960; the risk of germ cell tumours increased significantly among young cohorts of 1965-1980; and the risk of sex cord-stromal tumours dropped constantly among cohorts 1910-1950. Various period patterns by histology subtypes observed in this study suggested changes in histology classification criteria over the period. Further studies need to consider the various etiologies and the classification criteria changes according to histology subtypes.

KRN8602 (MX2-hydrochloride): an active new agent for the treatment of recurrent high-grade glioma

PURPOSE

To assess the efficacy and toxicity of KRN8602 when administered as an intravenous bolus to patients with recurrent high-grade malignant glioma.

PATIENTS AND METHODS

Patients with recurrent or persistent anaplastic astrocytoma or glioblastoma multiforme who had not received recent chemotherapy or radiotherapy and were of good performance status (Eastern Cooperative Oncology Group score < or = 2) were treated with an intravenous bolus of 40 mg/m(2) KRN8602 every 28 days. Tumor responses were assessed radiologically and clinically after every second cycle of therapy. Treatment was continued until documented progression or a total of six cycles.

RESULTS

A median of three cycles (range, one to six cycles) of KRN8602 was administered to 55 patients, 49 of whom received at least two cycles and were, therefore, assessable for response. The overall response rate (disease stabilization or better) was 43% (95% confidence interval, 29% to 58%). There were three complete responses, one partial response, seven minor responses, and 10 patients with stable disease. The median time to progression was 2 months (range, 1.5 to 37 months) and overall survival was 11 months (range, 1.5 to 40 months). Neutropenia was the most common toxicity, although it was generally of brief duration, and there were only seven episodes of febrile neutropenia in 176 cycles delivered. Nonhematologic toxicity was mostly gastrointestinal (nausea and vomiting, diarrhea) and events were grade 2 or lower except for a single episode of grade 3 vomiting.

CONCLUSION

KRN8602 is an active new agent with minimal toxicity in the treatment of relapsed or refractory high-grade glioma. Further studies with KRN8602 in combination with other cytotoxics and in adjuvant treatment of gliomas are warranted.

The application of a linear algebra to the analysis of mutation rates

Cells and bacteria growing in culture are subject to mutation, and as this mutation is the ultimate substrate for selection and evolution, the factors controlling the mutation rate are of some interest. The mutational event is not observed directly, but is inferred from the phenotype of the original mutant or of its descendants; the rate of mutation is inferred from the number of such mutant phenotypes. Such inference presumes a knowledge of the probability distribution for the size of a clone arising from a single mutation. We develop a mathematical formulation that assists in the design and analysis of experiments which investigate mutation rates and mutant clone size distribution, and we use it to analyse data for which the classical Luria-Delbrück clone-size distribution must be rejected.

Gamma interferon (IFN-gamma) receptor null-mutant mice are more susceptible to herpes simplex virus type 1 infection than IFN-gamma ligand null-mutant mice

Mouse strains with null mutations in the gamma interferon gene (Ifng) or the gamma interferon receptor gene (Ifngr) have been engineered. The use of these strains as animal models of viral and bacterial infections has enhanced our understanding of the role of gamma interferon (IFN-gamma) in the host immune response. However, direct comparisons between Ifng-/- (GKO) and Ifngr-/- (RGKO) mice have been problematic because previously available strains of these mice have had different genetic backgrounds (i.e., C57BL/6 and BALB/c for GKO mice and 129/Sv//Ev for RGKO mice). To enable direct comparison of herpes simplex virus type 1 (HSV-1) infections in GKO and RGKO mice, we introduced the IFN-gamma null mutation into the 129/Sv//Ev background. We report that, after HSV-1 inoculation, mortality was significantly greater in RGKO mice than in GKO mice (38 versus 23%, P = 0.0001). Similarly, the mortality from vaccinia virus challenge was significantly greater in RGKO mice than in GKO mice. With differences in genetic background excluded as a confounding issue, these results are consistent with the existence of an alternative ligand(s) for the IFN-gamma receptor that is also capable of mediating protection against viral challenge.

Creatine uptake in isolated soleus muscle: kinetics and dependence on sodium, but not on insulin

The increased use of creatine by athletes as a dietary supplement to improve their physical performance assumes that increased serum creatine levels will increase intracellular skeletal muscle creatine. Despite this common assumption, skeletal muscle creatine uptake awaits full characterization. Consequently, we have investigated 14C-labelled creatine uptake in isolated, incubated rat soleus (type I) muscle preparations at 37 degrees C. We found that the apparent Km for creatine uptake was 73 microM and the Vmax was 77 nmol h-1 gww-1. Creatine uptake was 82% inhibited by 2 mM beta-guanidinopropionic acid, the structural analogue of creatine. In addition, a decrease in buffer Na+ concentration, from 145 to 25 mM, reduced the rate of 14C-labelled creatine uptake by 77%, indicating that uptake is largely Na+-dependent in soleus muscle. Insulin had no effect on the rate of creatine uptake in vitro. The total creatine content was 34% lower, but the rate of creatine uptake in the presence of 100 microM extracellular creatine was 45% higher, in soleus than in extensor digitorum longus (type II) muscle. However, at 1 mM extracellular creatine, the maximal rate of uptake was not significantly different for the two muscle types, implying that soleus muscle has a lower Km for creatine uptake. We suggest that intracellular creatine levels may play a role in the regulation of skeletal muscle creatine uptake.

Osmotic shock: modulation of contractile function, pHi, and ischemic damage in perfused guinea pig heart

To determine the contribution of changes in extracellular osmolarity to ischemic injury, isolated guinea pig hearts were perfused with hyposmotic (220 mosM) or hyperosmotic (380 mosM) buffer. 31P NMR spectroscopy was used to follow changes in intracellular pH (pHi) and energetics. Hyposmotic buffer decreased myocardial developed pressure by 30 +/- 2% and pHi by 0.02 +/- 0.01 unit, whereas hyperosmotic buffer increased myocardial developed pressure by 34 +/- 1% and pHi by 0.14 +/- 0.01 unit. All hearts recovered to control values on restoration of isosmotic (300 mosM) buffer. The hyperosmolar-induced intracellular alkalosis and developed pressure increase were not prevented by inhibition of Na+/H+ exchange with use of 1 microM HOE-642 but were abolished with use of bicarbonate-free buffers. After 20 min of total global ischemia, hearts perfused with hyposmotic buffer showed significantly greater recoveries of developed pressure, phosphocreatine, and ATP than control hearts, but hearts perfused with hyperosmotic buffer did not recover after ischemia. In conclusion, buffer osmolarities between 220 and 380 mosM alter myocardial pHi and developed pressure but are not deleterious during perfusion. However, buffer osmolarity significantly alters the extent of myocardial ischemic injury.

Beyond palliative mastectomy in inflammatory breast cancer--a reassessment of margin status

BACKGROUND

Inflammatory breast cancer is a locally advanced tumor with an aggressive local and systemic course. Treatment of this disease has been evolving over the last several decades. The aim of this study was to assess whether current therapies, both surgical and chemotherapeutic, are providing better local control (LC) and overall survival (OS). We also attempted to identify clinical and pathologic factors that may be associated with improved OS, disease-free survival (DFS), and LC.

METHODS

A 25-year retrospective review performed at the City of Hope National Medical Center identified 90 patients with the diagnosis of inflammatory breast cancer.

RESULTS

Of the 90 patients identified with inflammatory breast cancer, 33 received neoadjuvant therapy (NEO) consisting of chemotherapy followed by surgery with radiation (n = 26) and without radiation (n = 7). Fifty-seven patients received other therapies (nonNEO). Treatments received by the nonNEO group consisted of chemotherapy, radiation, mastectomy, adrenalectomy, and oophorectomy, alone or in combination. The median follow-up was 28.9 months for the NEO group and 17.6 months for the nonNEO group. Borderline significant differences in the OS distributions between the two groups were found (P = .10), with 3- and 5-year OS for the NEO group of 40.0% and 29.9% and for the nonNEO group of 24.7% and 16.5%, respectively. DFS and LC were comparable in the two groups. Lower stage was associated with an improved OS (P < .05). The 5-year OS for stage IIIB was 30.9%, compared to 7.8% for stage IV. In those patients with stage III disease who were treated with mastectomy and rendered free of disease, margin status was identified by univariate analysis to be a prognostic indicator for OS (P < .05). The 3-year OS, DFS, and LC for patients with negative margins were 47.4%, 37.5%, and 60.3%, respectively, compared to 0%, 16.7%, and 31.3% in patients with positive margins.

CONCLUSIONS

This study suggests that in patients with inflammatory breast cancer and nonmetastatic disease, an aggressive surgical approach may be justified with the goal of a negative surgical margin. Achievement of this local control is associated with a better overall outcome for this subset of patients. The ability to obtain negative margins may further identify a group of patients with a less aggressive tumor biology that may be more responsive to other modalities of therapy.

Effective pain relief with intrapleural analgesia

The use of an intrapleural catheter for pain relief following cholecystectomy, renal surgery or unilateral breast surgery was first described in 1984 by Kvalheim and Reiestad. Despite seemingly positive reviews (Tartiere et al, 1991), the use of this technique for managing acute pain is still not commonplace even though it has been described as a superior method of analgesia (Gibson, 1994). This article describes the successful use of intrapleural analgesia under two different circumstances: first, postoperatively following open cholecystectomy and, second, following an accident in which the patient sustained several unilateral rib fractures.

The value of late computed tomographic scanning in identification of vascular abnormalities after abdominal aortic aneurysm repair

PURPOSE

The purpose of this study was to determine the prevalence of late arterial abnormalities after aortic aneurysm repair and thus to suggest a routine for postoperative radiologic follow-up examination and to establish reference criteria for endovascular repair.

METHODS

Computed tomographic (CT) scan follow-up examination was obtained at 8 to 9 years after abdominal aortic aneurysm (AAA) repair on a cohort of patients enrolled in the Canadian Aneurysm Study. The original registry consisted of 680 patients who underwent repair of nonruptured AAA. When the request for CT scan follow-up examination was sent in 1994, 251 patients were alive and potentially available for CT scan follow-up examination and 94 patients agreed to undergo abdominal and thoracic CT scanning procedures. Each scan was interpreted independently by two vascular radiologists.

RESULTS

For analysis, the aorta was divided into five defined segments and an aneurysm was defined as a more than 50% enlargement from the expected normal value as defined in the reporting standards for aneurysms. With this strict definition, 64.9% of patients had aneurysmal dilatation and the abnormality was considered as a possible indication for surgical repair in 13.8%. Of the 39 patients who underwent initial repair with a tube graft, 12 (30.8%) were found to have an iliac aneurysm and six of these aneurysms (15.4%) were of possible surgical significance. Graft dilatation was observed from the time of operation (median graft size of 18 mm) to a median size of 22 mm as measured by means of CT scanning at follow-up examination. Fluid or thrombus was seen around the graft in 28% of the cases, and bowel was believed to be intimately associated with the graft in 7%.

CONCLUSION

Late follow-up CT scans after AAA repair often show vascular abnormalities. Most of these abnormalities are not clinically significant, but, in 13.8% of patients, the thoracic or abdominal aortic segment was aneurysmal and, in 15.4% of patients who underwent tube graft placement, one of the iliac arteries was significantly abnormal to warrant consideration for surgical repair. On the basis of these findings, a routine CT follow-up examination after 5 years is recommended. This study provides a population-based study for comparison with the results of endovascular repair.

Localization of human BRCA1 and its loss in high-grade, non-inherited breast carcinomas

Although the link between the BRCA1 tumour-suppressor gene and hereditary breast and ovarian cancer is established, the role, if any, of BRCA1 in non-familial cancers is unclear. BRCA1 mutations are rare in sporadic cancers, but loss of BRCA1 resulting from reduced expression or incorrect subcellular localization is postulated to be important in non-familial breast and ovarian cancers. Epigenetic loss, however, has not received general acceptance due to controversy regarding the subcellular localization of BRCA1 proteins, reports of which have ranged from exclusively nuclear, to conditionally nuclear, to the ER/golgi, to cytoplasmic invaginations into the nucleus. In an attempt to resolve this issue, we have comprehensively characterized 19 anti-BRCA1 antibodies. These reagents detect a 220-kD protein localized in discrete nuclear foci in all epithelial cell lines, including those derived from breast malignancies. Immunohistochemical staining of human breast specimens also revealed BRCA1 nuclear foci in benign breast, invasive lobular cancers and low-grade ductal carcinomas. Conversely, BRCA1 expression was reduced or undetectable in the majority of high-grade, ductal carcinomas, suggesting that absence of BRCA1 may contribute to the pathogenesis of a significant percentage of sporadic breast cancers.

On scene thoracotomy: a case report

We report a case of on scene resuscitative thoracotomy performed by an anaesthetist on a patient in cardiac arrest following a stab wound to the chest. The patient made a good recovery and was discharged from hospital within 2 weeks. The rationale for performing resuscitative thoracotomy and who should perform this procedure are discussed.

Modelling myocardial ischaemia and reperfusion

Substrate depletion and increased intracellular acidity are believed to underlie clinically important manifestations of myocardial ischaemia. Recent advances in measuring ion concentrations and metabolite changes have provided a wealth of detail on the processes involved. Coupled with the rapid increase in computing power, this has allowed the development of a mathematical model of cardiac metabolism in normal and ischaemic conditions. Pre-existing models of cardiac cells such as Oxsoft HEART contain highly developed dynamic descriptions of cardiac electrical activity. While biophysically detailed, these models do not yet incorporate biochemical changes. Modelling of bioenergetic changes was based and verified against whole heart NMR spectroscopy. In the model, ATP hydrolysis and generation are calculated simultaneously as a function of [Pi]i. Simulation of pH regulation was based on the pHi dependency of acid efflux, examined in time-course studies of pHi recovery (measured in myocytes with the fluorophore carboxy-SNARF-1) from imposed acid and alkali loads. The force-[Ca2+]i relationship of myofibrils was used as the basis of modelling H+ competition with Ca2+, and thus of pH effects on contraction. This complex description of biochemically important changes in myocardial ischaemia was integrated into the OXSOFT models. The model is sufficiently complete to simulate calcium-overload arrhythmias during ischaemia and reperfusion-induced arrhythmias. The timecourse of both metabolite and pH changes correlates well with clinical and experimental studies. The model possesses predictive power, as it aided the identification of electrophysiological effects of therapeutic interventions such as Na(+)-H+ block. It also suggests a strategy for the control of cardiac arrhythmias during calcium overload by regulating sodium-calcium exchange. In summary, we have developed a biochemically and biophysically detailed model that provides a novel approach to studying myocardial ischaemia and reperfusion.

Age-specific patterns of factors related to fatal motor vehicle traffic crashes: focus on young and elderly drivers

This population-based study examines patterns of fatal motor vehicle traffic crashes (MVTCs) by age group (16-24, 25-64, 65+) among Canadian drivers. The Canadian Traffic Accident Information Databank (TRAID) provided information about fata MVTCs between 1984 and 1993. Distribution of risk factors was compared by age group. Crude odds ratios and 95% CIs were calculated for both young and elderly drivers compared with middle-aged drivers. The middle-age group was selected as reference population since it demonstrates the lowest risk of fatality. Compared to the middle-aged group, young drivers demonstrated excess risk for (1) risk-taking behaviours and conditions, specifically alcohol and illicit drug use, speeding, non use of seat belts, fatigue and falling asleep, and inexperience; (2) crashes during the summer, during weekends and at night; and (3) single-vehicle collisions and on performing overtaking manoeuvres. Excess risk among elderly drivers was noted for (1) medical and physical conditions, inattention and inexperience; (2) driver actions, for example, improper turning, failure to yield right-to-way; (3) occurrence on weekdays and during the day; and (4) collisions at intersection and vehicle--vehicle sideswipes. The results show notable differences in risk factors by age group and confirm the need for preventive efforts that incorporate age-specific strategies.

Effect of gap length and position on results of treatment of cancer of the larynx in Scotland by radiotherapy: a linear quadratic analysis

PURPOSE

This paper reports on the analysis of the effect of the length and position of unplanned gaps in radiotherapy treatment schedules.

MATERIALS AND METHODS

Data from an audit of the treatment of carcinoma of the larynx are used. They represent all newly diagnosed cases of glottic node-negative carcinoma of the larynx between 1986 and 1990, inclusive, in Scotland that were referred to one of the five Scottish Oncology Centres for primary radical radiotherapy treatment. The end-points are local control of cancer of the larynx in 5 years and the length of the disease-free period. The local control rates at > or =5 years, Pc were analyzed by log linear models and Cox proportional hazard models were used to model the disease-free period.

RESULTS

Unplanned gaps in treatment are associated with poorer local control rates and an increased hazard of a local recurrence through their effect on extending the treatment time. A gap of 1 day is potentially damaging but the greatest effect is at treatment extensions of 3 or more days, where the hazard of a failure of local control is increased by a factor of 1.75 (95% confidence interval 1.20-2.55) compared to no gap. The time factor for the actual time was imprecisely estimated at 2.7 Gy/day with a standard error of 13.2 Gy/day. Among those cases who had exactly one gap resulting in a treatment extension of 1 day, there is no evidence that gap position influences local control (P = 0.17). The treatment extension as a result of the gap is more important than the position of the gap in the schedule.

CONCLUSIONS

Gaps in the treatment schedule have a detrimental effect on the disease-free period. A gap has a slightly greater effect than an increase in the prescribed treatment time. Any gap in treatment is potentially damaging. The position of the gap in the schedule was shown to be not important.

Workshop report. National initiative to improve cancer survival information

This workshop (held June 19 20, 1997, in Ottawa, Ontario) brought together major stakeholders to establish a Canadian initiative to develop systematic collection of population-based information on cancer survival. The broad goals of the workshop were to delineate the current needs regarding such data and to recommend practical mechanisms to systematically generate this information. Three key areas for discussion were identified: collection of staging data, collection of treatment data and standardized approaches to analysis. Presentations (summarized in report), designed to establish common ground for workshop discussions, provided background information on population-based collection mechanisms, data and methodology requirements for conducting meaningful cancer survival surveillance, and practical examples of using cancer survival information.

Phase I and pharmacokinetic study of KRN8602 alone and with filgrastim in patients with advanced cancer

PURPOSE

To determine the recommended dose, toxicity profile, and pharmacokinetics of KRN8602 (MX2-hydrochloride), a novel morpholino anthracycline with potent cytotoxicity against anthracycline-sensitive and resistant experimental tumors in vitro and in vivo.

PATIENTS AND METHODS

KRN8602 was administered alone in increasing doses to patients with advanced cancer or high-grade gliomas until dose-limiting toxicity (DLT) was observed in three or more of five patients treated in a dose level. Because neutropenia was dose limiting, further escalation was investigated with filgrastim support.

RESULTS

Fifty-six assessable patients completed at least one cycle of chemotherapy. The recommended dose of KRN8602 alone was 40 mg/m2. Dose escalation was limited by neutropenia. The recommended dose of KRN8602 with filgrastim was 70 mg/m2, and limiting toxicities were neutropenia, diarrhea, and vomiting. The most commonly experienced nonhematologic toxicity was nausea and vomiting. Alopecia and mucositis were infrequent and mild. Pharmacokinetic parameters showed substantial variation, although the area under the plasma concentration-time curve (AUC) and maximum concentration both increased with dose. There was no relationship between pharmacokinetic parameters and toxicity.

CONCLUSION

KRN8602 at doses of 40 mg/m2 when administered alone and 70 mg/m2 when administered with filgrastim appeared to be manageable. The major DLTs were neutropenia and, at higher doses, diarrhea and vomiting. The efficacy of this drug is currently being tested in phase II studies.

Management of upper extremity central venous obstruction using interventional radiology

Upper extremity central vein stenosis/occlusion is responsible for significant morbidity. The objective of this report is to review our management using interventional radiological techniques and to determine the long-term clinical results. All radiological interventions for central vein stenosis/occlusion (n = 59) between July 1991 and July 1996 at our institution were reviewed. The interventions consisted of thrombolytic therapy alone in 10 cases, PTA in 40 cases (combined with initial thrombolytic therapy in 6 cases), and deployment of a venous stent in 9 cases. At follow-up, the cumulative success (patency and relief of symptoms) was determined (Kaplan-Meier method). The involved vein was the subclavian, axillary, or innominate (SUB-AX-INN) in 45 cases and the superior vena cava (SVC) in 14 cases. The etiology was secondary to an indwelling foreign body (catheter, pacemaker lead) in 53 cases (90%), and spontaneous in only 6 cases (10%). The average follow-up after intervention was 17.2 months, with a cumulative success of 70 +/- 7.5% at 2 years, with rapid decline thereafter. Analysis of the failure quantiles revealed that 25% failed by 17 months, 50% failed by 26.6 months, and 75% failed by 33.8 months. There were no subgroup differences (log-rank test) for stenosis versus occlusion (p = 0.526), SUB-AX-INN versus SVC (p = 0.744), or if the intervention was begun < 5 days versus > or =5 days after symptom onset (p = 0.240), or whether or not a stent was deployed (p = 0.893). Interventional radiological techniques should be considered when symptoms from upper extremity central vein stenosis/occlusion are severe and disabling, or when veno-access or maintenance of patency of an ipsilateral arteriovenous (A-V) access is necessary. These results suggest an acceptable short-to medium-term solution.