Prolonged fixed dose rate infusion of gemcitabine with autologous haemopoietic support in advanced pancreatic adenocarcinoma

This study aimed to define the maximum-tolerated dose (MTD) of fixed dose rate (FDR) of gemcitabine (2′-2′-difluorodeoxycitidine) infusion with circulating haemopoietic progenitor support and to evaluate the activity of the treatment. Secondary end points were pharmacokinetic of gemcitabine and difluorodeoxyuridina (dFdU) measured at first course and the activity andexpression profile of cytidine deaminase (CdA) on circulating mononuclear cells. Patients with advanced pancreatic carcinoma received escalating dose of gemcitabine 10 mg m⁻² min⁻¹ every 2 weeks with circulating haemopoietic progenitor support. First dose level was 3000 mg m⁻² and the doses were increased by 500 mg m⁻² until MTD. In all, 23 patients were enrolled. Toxicities were mild or moderate; the only patient treated at 7000 mg m⁻² died because of toxicity; therefore; the MTD was established at 6500 mg m⁻². The overall response rate was 22.2%. The AUC of gemcitabine showed a dose-dependent increase, while the AUC of dFdU reached a plateau at 4500 mg m⁻². A significant relationship was found between the AUC of dFdU and CdA expression and activity (P<0.05). Moreover, progression rate and survival were significantly related to CdA expression and activity levels. The activity of high-dose gemcitabine is not superior to that reported with less intensive FDR schedules. The predictive role of CdA expression and activity on outcome deserves further investigation.

First-line treatment of metastatic colorectal cancer with irinotecan, oxaliplatin and 5-fluorouracil/leucovorin (FOLFOXIRI): results of a phase II study with a simplified biweekly schedule

BACKGROUND

In a previous phase I-II study we demonstrated that the FOLFOXIRI regimen [irinotecan 125-175 mg/m2 day 1, oxaliplatin 100 mg/m2 day 1, l-leucovorin (l-LV) 200 mg/m2 day 1, 5-fluorouracil (5-FU) 3800 mg/m2 as a 48-h chronomodulated continuous infusion starting on day 1, repeated every 2 weeks] has promising activity and efficacy in metastatic colorectal cancer. However, this regimen required a chronomodulated infusion of 5-FU, and because neutropenia occurred in 32% of cycles, granulocyte colony-stimulating factor (G-CSF) was used and the delivered dose intensity was only approximately 78% of planned. Therefore, we conducted the present phase II study in order to develop a simplified FOLFOXIRI regimen that could be more easily administered in clinical practice as well as in multicenter settings.

PATIENTS AND METHODS

A total of 32 patients with unresectable metastatic colorectal cancer received irinotecan 165 mg/m2 day 1, oxaliplatin 85 mg/m2 day 1, l-LV 200 mg/m2 day 1 and 5-FU 3200 mg/m2 as a 48-h continuous (not chronomodulated) infusion starting on day 1, repeated every 2 weeks.

RESULTS

All 32 patients were evaluated for safety and the incidence of grade 3-4 toxic effects, and the use of G-CSF seemed to be lower than with the previous FOLFOXIRI regimen: grade 4 neutropenia (34%), grade 3 diarrhea (16%), grade 3 stomatitis (6%) and grade 2-3 peripheral neurotoxicity (37%) were reported, and G-CSF was used in 23% of cycles. Delivered dose intensity was 88% of that planned, and no toxic deaths occurred. The intention-to-treat analysis for activity showed four complete responses, 19 partial responses, seven stable disease and two progressive disease, for an overall response rate of 72% (95% confidence interval 53% to 86%). Eight (25%) patients with residual liver or lung metastases were radically resected after chemotherapy. After a median follow-up of 18.1 months, the median progression-free survival is 10.8 months and median survival is 28.4 months.

CONCLUSIONS

This simplified FOLFOXIRI combination can be delivered easily in outpatient settings, with manageable toxic effects, and has very promising antitumor activity. While the safety profile seems to be improved in comparison with our previous FOLFOXIRI regimen, antitumor activity and efficacy appear to be maintained.

Sciatic Nerve Varices

OBJECTIVE(S)

To describe patients presenting with sciatic nerve varices (SNV), presenting pitfalls in diagnosis and management.

DESIGN

Case series.

METHODS

Patients were investigated using duplex ultrasonography pre-operatively in three cases. Treatment was undertaken both by surgery and by foam sclerotherapy.

RESULTS

Clinically, SNV appeared just below the popliteal skin crease, lateral to the small saphenous vein (SSV). In two cases SNV occurred alone, in two further cases SNV occurred in conjunction with varices from other sources. Symptoms of 'sciatic' pain were present in all. Foam sclerotherapy (1% Polidocanol) was undertaken in one case with a varix. Complete obliteration of the vein and resolution of all symptoms was achieved at the 1-month follow-up examination. Surgical management was used in the other cases.

CONCLUSION

The sciatic nerve vein follows the fibular saphenous nerve (lying superficial to the fascia in the leg). This nerve arises from the common peroneal nerve (in the popliteal fossa), and is a major branch of the sciatic nerve. Varices of the associated vein appear to be the result of a dysplasia. This condition may be more common than is currently recognised.

Increased dose-intensity of gemcitabine in advanced non small cell lung cancer (NSCLC): a multicenter phase II study in elderly patients from the "polmone toscano group" (POLTO)

Gemcitabine is usually administered at a planned dose-intensity (DI) from 750 to 800 mg/m2/week. Preclinical data have suggested a possible dose-response relationship of gemcitabine. A multicenter phase II study was conducted to evaluate the activity in terms of no progression rate (complete responses+partial responses+stable diseases) of gemcitabine administered at an increased DI (1000 mg/m2/week) in elderly advanced non-small-cell lung cancer (NSCLC) patients. Secondary endpoints were to evaluate tolerability, progression free survival and overall survival. Elderly (age>or=70 years) chemo-naive advanced NSCLC patients, ECOG PS 0-2, were treated with intravenous gemcitabine 1500 mg/m2 intravenous (30 min infusion) on days 1 and 8 every 21 days for four courses. One hundred and twenty-two patients with a median age of 75 years (range 70-84) entered the study. The following grade 3 (NCI-CTC) haematological toxicities were reported (percent of patients): neutropenia 2.4%, thrombocytopenia 1.6%, anaemia 2.4%. No grades 3-4 non-haematological toxicities were observed. Among 111 evaluable patients 52 (46.8%) no progressions, 17 (15.3%) partial responses (WHO criteria), 35 (31.5%) stable diseases and 59 (53.2%) progressions were observed. Median time to progression was 3.2 months and median duration of survival was 5.4 months. The overall 1-year survival rate was 27%. Although increased dose-intensity of gemcitabine in elderly NSCLC patients is feasible without severe toxicities, this does not seem to be associated with an increased activity and efficacy in comparison to standard gemcitabine regimens with lower dose-intensities.

Numerical model to predict the longterm mechanical stability of cementless orthopaedic implants

The objective of this research was to develop a purely biomechanical model, intended to predict the long-term secondary stability of the implant starting from the biomechanical stability immediately after the operation. A continuous rule-based adaptation scheme was formulated as a dynamic system, and the work verified if such a model produced unique and clinically meaningful solutions. It also investigated whether this continuous model provided results comparable with those of a simpler, discrete-states model used in a previous study. The proposed model showed stable convergence behaviour with all investigated initial conditions, with oscillatory behaviour limited to the first steps of the simulation. The results obtained with the wide range of initial conditions support the hypothesis of the existence and uniqueness of the solution for all initial conditions. The differences between the continuous model and the simpler and more efficient finite-states model were found to be extremely modest (less than 4% over the predicted bonded area). Because of these minimal differences, the use of the much faster finite-states model is recommended to investigate asymptotic conditions, and the continuous model described should be used to investigate the evolution over time of the adaptive process.

Stop-flow technique for loco-regional delivery of high dose chemotherapy in the treatment of advanced pelvic cancers

AIM

To verify the rationale of a pelvic stop-flow technique for the perfusion of high-doses of mitomycin C and anthacyclines in patients with inoperable, recurrent pelvic cancer.

METHODS

The stop-flow technique was realized by using percutaneous double-balloon arterial-venous catheters that selectively isolate the pelvic vascular section and a perfusion provided by an extracorporeal pump for 20 min. Ten patients (pts) with unresectable pelvic recurrence from colon-rectal cancer were treated with a combination of Mitomycin C (MMC, 20 mg/sqm) plus doxorubicin (DOXO, 75 mg/sqm; 8pts) or epirubicin (EPI, 75 mg/sqm; 2pts) infused into the isolated pelvic compartment. Blood samples were collected from the extracorporeal vascular flow and from peripheral plasma, and analysed for drug quantitation.

RESULTS

During the procedure, there were no technical or hemodynamic complications, and no deaths occurred during surgery or in the postoperative period. MMC and DOXO peak levels measured in the extracorporeal system which irrotates the tumor area, were on average 21.6 (range: 4.3-44.3, MMC) and 17.2 (range: 1.8-48.4, DOXO) times higher than those observed in the peripheral blood. Similarly; the area under concentration (AUC) versus time curves measured in the pelvic compartment during stop-flow perfusion were 19.9 (range: 3.8-45.0, MMC) and 13.4 (range: 1.2-26.6, DOXO) times higher than the corresponding value in peripheral circulation. The drug percentage eliminated in the ultra filtrate was only 7.7% (MMC) and 0.9% (DOXO), and the plasmatic AUC(0-24) were similar to those observed with iv bolus of equivalent drug doses. Minimal systemic and local toxicities were observed. One complete pathological and 2 partial responses were observed; pain remission in 8/10 patients. median survival was 12 months (8-31).

CONCLUSION

The endo-arterial administration into the local vasculature produces high pelvic-systemic concentration gradients during the stop-flow perfusion with limited local and systemic toxicity. The encouraging clinical results suggest further evaluation.

Activity of first-line epirubicin and paclitaxel in metastatic breast cancer is independent of type of adjuvant therapy

To evaluate the impact of prior adjuvant chemotherapy on response rate (RR), progression-free (PFS) and overall survival (OS) of metastatic breast cancer patients treated with epirubicin/paclitaxel (ET) regimens. In all, 291 patients enrolled in five studies in metastatic breast cancer were analysed: 101 (35%) were chemonaive, 109 (37%) had received adjuvant CMF and 81 (28%) adjuvant anthracyclines. Response rate to ET was 66%. Response rate was 63% for cyclophosphamide plus methotrexate plus 5-fluorouracil (CMF), 67% for prior anthracyclines and 68% in chemonaive patients (P=0.5). By multivariate analysis, adjusted odds ratio for response was 0.81 (95% CI: 0.37-1.79) for CMF and 0.92 (95% CI 0.43-2.01) for anthracyclines (P=0.86). The CR rates were 14% for both CMF and anthracyclines and 22% for chemonaive patients (P=0.2). By multivariate analysis, the relative odds of CR for CMF or anthracyclines were 0.40 and 0.39 as compared to chemonaive patients (P=0.036). The median PFS was 11.0 months for prior CMF, 10.2 months for anthracyclines and 12.5 months in chemonaive patients (P=0.33). In multivariate Cox's model, a nonsignificant increase in the risk of progression was seen in patients treated with adjuvant CMF or anthracyclines. The median OS was 23.8 months for CMF, 20.2 months for anthracyclines and 27.5 months in chemonaive patients (P=0.61). The same, nonsignificant, association was seen in multivariate analysis. The ET regimens provide satisfactory results in metastatic breast cancer, regardless of previous adjuvant chemotherapy.

The "T" vein of the leg

BACKGROUND

We frequently observe a tributary of the saphenous vein with the origin in the saphenous compartment of the medial aspect of the upper third of the leg. It runs transversally in the interfascial compartment toward the lateral aspect of the leg. Constantly it feeds by reflux varicose veins clinically visible in the paratibial region and/or in the lateral aspect of the leg. For the peculiarity of its anatomical shape as well as duplex appearance, we defined it as the "T" vein.

OBJECTIVES

To assess how frequently the "T" vein of the leg is involved in varicose networks.

METHODS

A total of 218 consecutive patients affected by primary varicose veins have been evaluated by the means of duplex scanning. We assessed both the presence of the above-mentioned tributary and the frequency of its hemodynamic involvement in the varicose network.

RESULTS

In 15 of 218 cases (7%) we demonstrated the above-mentioned tributary with an interfascial length ranging between 5 and 12 cm involved in varicose networks.

CONCLUSIONS

The anterior tributary of the saphenous vein of the anterolateral aspect of the leg is a neglected clinical entity, whose existence is important to know for the treatment of varicose veins of the lateral aspect of the leg.

A novel ultrasound instrument for investigation of arterial mechanics

The study of arterial mechanics concerns functional characteristics depending on wall elasticity and flow profile. Wall elasticity can be investigated through the estimation of parameters like the arterial distensibility, which is of high clinical interest because of its known correlation not only with the advanced atherosclerotic disease, but also with aging and major risk factors for cardiovascular disease. The flow velocity profile is also clinically relevant, because it modulates endothelial function and can be responsible for the development and distribution of atherosclerotic plaques. A clinically relevant variable extracted from the blood velocity profile is the wall shear rate (WSR), which represents the spatial velocity gradient near the vessel wall. This paper describes an integrated ultrasound system, capable of detecting both the velocity profile and the wall movements in human arteries. It basically consists of a PC add-on board including a single high-speed digital signal processor. This is dedicated to the analysis of echo-signals backscattered from 128 range cells located along the axis of the interrogating ultrasound (US) beam. Echoes generated from the walls (characterized by high amplitudes and low Doppler frequencies) and from red blood cells (characterized by low amplitudes and relatively high Doppler frequencies) are independently processed in real-time. Wall velocity is detected through the autocorrelation algorithm, while blood velocity is investigated through a complete spectral analysis of all signals backscattered by erythrocytes and WSR is extracted from the estimated velocity profile. Preliminary applications of the new system, including the simultaneous analysis of blood flow and arterial wall movement in healthy volunteers and in a diseased patient, are discussed, and first results are presented.

Spinal cord lesion management in Italy: a 2-year survey

DESIGN

Prospective 2-year survey from 1 February 1997 to 31 January 1999.

OBJECTIVES

To compare the route from injury to rehabilitation, and the outcome of care in a large sample of traumatic (T) and nontraumatic (NT) spinal cord lesion (SCL) patients at their 'first admission'.

SETTING

T and NT SCI patients consecutively admitted to 37 SCL centres in Italy.

METHOD

Data were recorded on simple, computerised, closed-question forms, which were Centrally collected and analysed. Descriptive and inferential analysis was conducted to define the characteristics and compare the T and NT populations, and to identify correlations among the variables examined: time from the event to admission (TEA); pressure sores (PS) on admission; length of stay (LoS) and destination on discharge.

RESULTS

A total of 1014 SCL patients, 67.5% with a lesion of T and 32.5% of NT aetiology were analysed. The subjects in the T group were younger (median 34 versus 58 years), with higher probability of cervical involvement (OR 2.47, CI 1.8-3.4) and completeness of the lesion (OR 3.0, CI 2.3-4.0), shorter median TEA (37 versus 64 days, P<0.0001) and less frequent admission from home (3.6 versus 17.4%) compared to the NT group. TEA and PS on admission were analysed as indicators of the efficacy of the courses from injury to rehabilitation. Longer TEA was reported for people with NT aetiology, admitted to rehabilitation centre (RC), not locally resident, transferred from certain wards and to a lesser degree female subjects and those with complications on admission. PS were associated to completeness of lesion, longer TEA, admission to RC, nonlocal residence and coming from general intensive care units, or general surgery wards. Median LoS was 99 days (mean 116 and range 0-672), and was statistically shorter in the NT group (122 versus 57 median, P<0.00001). Upon discharge, bladder and bowel autonomy were, respectively, obtained in 68.1 and 64.5% of the whole population without significant difference between the T and NT groups. A total of 80.2% of patients were discharged home and the following factors: not living alone, being discharged after longer LoS, having sphincterial autonomy and no PS, were all independent predictors of outcome.

CONCLUSION

There are important obstacles in the admission route to rehabilitation facilities, greater for NT, as longer TEA and more complications on admission testify. Moreover, the LoS is shorter for NT population. Our findings suggest that rehabilitation outcome could be improved through an early multidisciplinary approach and better continuity between acute and rehabilitation care, especially for the 'neglected' NT SCL patients.

Embolism from the heart in the young patient: a short review

Embolism from the heart causes about one-fifth of ischemic strokes and transient ischemic attacks. Although a potential embolic source may be found in up to one-third of cases, which are actually caused by other mechanisms, in the young patient more than one source of embolism is less likely. The most-important embolic sources are non-rheumatic and rheumatic atrial fibrillation (AF), infective endocarditis, prosthetic heart valves, recent myocardial infarction, dilated cardiomyopathy, intracardiac tumors, and rheumatic mitral stenosis. Uncomplicated mitral valve prolapse should no longer be considered a cause of embolism from the heart to the brain; an additional disorder (i.e., gross mitral regurgitation, AF, infective endocarditis) must be present to suggest a cardioembolic origin of the stroke.

Phase III randomized trial comparing three platinum-based doublets in advanced non-small-cell lung cancer

PURPOSE

To evaluate whether two commonly used newer platinum-based regimens offer any advantage over vinorelbine-cisplatin (reference regimen) in response rate for patients with advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Chemotherapy-naive patients were randomized to receive gemcitabine 1,250 mg/m(2) days 1 and 8 plus cisplatin 75 mg/m(2) day 2 every 21 days (GC arm), or paclitaxel 225 mg/m(2) (3-hour infusion) then carboplatin (area under the concentration-time curve of 6 mg/mL x min), both on day 1 every 21 days (PCb arm), or vinorelbine 25 mg/m(2)/wk for 12 weeks then every other week plus cisplatin 100 mg/m(2) day 1 every 28 days (VC arm).

RESULTS

Six hundred twelve patients were randomized to treatment (205 GC, 204 PCb, and 203 VC). Overall response rates for the GC (30%) and PCb (32%) arms were not significantly different from that of the VC arm (30%). There were no differences in overall survival, time to disease progression, or time to treatment failure. Median survival for the GC, PCb, and VC groups was 9.8, 9.9, and 9.5 months, respectively. Neutropenia was significantly higher on the VC arm (GC 17% or PCb 35% v VC 43% of cycles, P <.001), as was thrombocytopenia on the GC arm (GC 16% v VC 0.1% of cycles, P <.001). Alopecia and peripheral neurotoxicity were most common on the PCb arm, as was nausea/vomiting on the VC arm (P <.05).

CONCLUSION

Efficacy end points were not significantly different between experimental and reference arms, although toxicities showed differences. These findings suggest that chemotherapy in NSCLC has reached a therapeutic plateau.