Retrospective analysis of 25 women with malignant cystosarcoma phyllodes--treatment results

PURPOSE

Mastectomy without axillary dissection should be the standard treatment in patients with malignant form of cystosarcoma phyllodes. The role of postoperative radiotherapy and chemotherapy remains to be fully established. We evaluate treatment results in a group of patients with cystosarcoma phyllodes (CP) treated at our Institute.

PATIENTS AND METHODS

In this report we analyze treatment outcome in 25 patients with malignant cystosarcoma phyllodes treated at Masaryk Memorial Cancer Institute between 1970 and 1995. Mean tumor size was 10 cm in diameter. All patients underwent surgery. Subsequently, 17 patients (68%) received radiotherapy on the breast or chest wall.

RESULTS

Median follow-up was 139.5 months. Local recurrence was observed in 16% of all patients and all patients with local recurrence died. Time to local relapse after surgery was 4-11 months. Distant metastases occurred in 5 patients. All patients with local recurrence had distant metastases. Dissemination occurred 3-19 months after local recurrence. Five-year survival of all patients was 80%.

CONCLUSION

A specific protocol for the treatment of cystosarcoma phyllodes is missing, probably due to rarity of the disease. The treatment of local recurrent disease remains unsuccessful in most CP patients. We recommend postoperative irradiation on the chest wall in patients with malignant form of CP, because adjuvant radiotherapy decreased the incidence of local relapse in our group of patients.

Surgical management of gynecologic rhabdomyosarcoma

The multidisciplinary treatment strategy for rhabdomyosarcoma (RMS) of the female gynecologic system is evidence of the progress made in the management of many childhood cancers. Previously, initial radical surgery (eg, complete vaginectomy, hysterectomy, and pelvic exenteration) and less effective single-agent chemotherapeutic agents were used with suboptimal results. Over the past 30 years, there has been an increase in overall survival with gynecologic RMS and a significant decrease in the hysterectomy and vaginectomy rates. The usual recommended treatment strategy for gynecologic RMS is initial biopsy to establish the diagnosis, followed by neoadjuvant chemotherapy. The specific chemotherapy regimen is selected based on the risk stratification of the particular patient, and this will often allow a more conservative surgical approach to be used, with the goal of complete tumor resection. Radiation therapy is considered before definitive surgical resection with minimal response to chemotherapy or after definitive surgical resection with positive margins. Recurrent or persistent RMS, including RMS of the female gynecologic system, represents a very aggressive disease with poor outcome. In these cases, aggressive management, including experimental chemotherapy agents and organ-sacrificing surgery, is often indicated to afford any chance of long-term survival. Continued enrollment of a high proportion of these patients into ongoing prospective clinical trials should allow the outcomes to continue to improve.

Soft tissue sarcomas

Sarcomas are a heterogeneous group of rare tumors that arise predominantly from the embryonic mesoderm. They present most commonly as an asymptomatic mass originating in an extremity but can occur anywhere in the body, particularly the trunk, retroperitoneum, or the head and neck. Pretreatment radiologic imaging is critical for defining the local extent of a tumor, staging the disease, guiding biopsies, and aiding in diagnosis. Core-needle biopsy is the preferred biopsy technique for diagnosing soft tissue sarcomas. The American Joint Committee on Cancer (AJCC) staging system for soft tissue sarcomas is based on histologic grade, the tumor size and depth, and the presence of distant or nodal metastases. Despite improvements in local control rates with wide local resections and radiation therapy, metastasis and death remain a significant problem in 50% of patients who present with high-risk soft tissue sarcomas. The most common site of metastasis is the lungs, and metastasis generally occurs within two to three years after the completion of therapy. Progress in the molecular characteristics of these tumors should in the near future translate into molecularly based therapies that can be incorporated into standard treatment strategies.

Efficiency of in vivo purging with rituximab prior to autologous peripheral blood progenitor cell transplantation in B-cellnon-Hodgkin’s lymphoma: a single institution study

BACKGROUND

Rituximab induces clinical response in advanced B-cell lymphoma and is efficient in removing circulating B-cell from peripheral blood. We therefore postulated that rituximab might be a useful in vivo purging agent before high-dose therapy in this setting.

PATIENTS AND METHODS

Fourteen patients with relapsed follicular, marginal zone and mantle cell lymphomas (11, two and one cases, respectively) and a PCR-detectable molecular marker were treated first with rituximab, then a mobilization chemotherapeutic regimen, followed by high-dose therapy with peripheral blood stem cell transplantation. PCR analyses were performed in peripheral blood before rituximab and during follow-up, and in harvest.

RESULTS

Harvests were free of PCR-detectable molecular marker in nine of the 11 studied cases (82%). After high-dose therapy, clinical complete remission was obtained in 13 (93%) patients and molecular remission in 11 (79%). With a median follow-up of 3 years, the 14 transplanted patients were alive, 11 of them remaining in clinical complete remission and eight in molecular remission at last follow-up.

CONCLUSION

Rituximab treatment followed by high dose therapy appears to be effective in achieving complete clinical and molecular response. In vivo harvest purging is predictive of prolonged clinical and molecular remission.

End results of salvage therapy after failure of breast-conservation surgery

About 10% to 15% of patients who undergo breast-conservation surgery and radiation therapy will subsequently develop ipsilateral breast tumor recurrence (IBTR). This paper reviews the biology, clinical management, and outcome of this entity. Risk factors for IBTR include young age, positive microscopic margins, gross multifocality, an extensive intraductal component, and lymphatic vessel invasion. The standard therapy following IBTR has been mastectomy, but interest in further breast-conservation approaches has recently arisen. Although the outcome following salvage therapy is quite good, the risk of distant metastases for patients with IBTR is three to five times greater than for those without recurrence. The reason for this association has been controversial, but it now appears that IBTR is both a marker of the underlying biologic aggressiveness of the tumor and a source for further tumor metastasis. Monitoring of patients following lumpectomy and radiation therapy, and aggressive therapy for IBTR when diagnosed, are clearly warranted. Prognostic factors at the time of IBTR and implications for local and systemic therapy are discussed.

Adenocarcinoma of the cervix

Cervical adenocarcinomas are increasing in incidence each year, comprising up to 25% of all cervical cancers diagnosed in the United States. This increase largely reflects the inherent difficulty in detecting glandular precursor lesions using current screening practices. However, there also appears to be a recent shift in the epidemiology of the disease process with younger women being diagnosed more frequently. Fertility-sparing surgery is an option for selected patients with adenocarcinoma in situ or stage IA(1) cervical adenocarcinoma. Simple hysterectomy should be performed at the completion of childbearing or when preserving fertility is not an issue. The treatment of choice for most women with stage IA(2) to IB(1) disease is radical hysterectomy. Fewer than 20% of patients will need adjuvant therapy and the cure rate is excellent. Primary radiation with weekly cisplatin may be the best option for patients with stage IB(2) to IIA cervical adenocarcinoma. Patients treated initially by primary radical surgery will almost certainly require postoperative chemoradiation because of high-risk surgical-pathologic features. Patients with stage IIB to IVA disease should also receive primary radiation with weekly cisplatin. Management of recurrence should be individualized, depending on the location of disease and the type of previous therapy.

Pelvic sidewall involvement in recurrent rectal cancer

BACKGROUND AND AIMS

The lateral pelvic sidewall is an area not routinely dissected during standard operative procedures in surgery for rectal cancer in Western countries. This study analyzed data to evaluate the pattern of recurrence in rectal cancer with special emphasis on lateral tumor extension in a recently treated patient population.

PATIENTS AND METHODS

In a multicenter retrospective study 123 patients were evaluated by our own CT-based three-dimensional datafile system and an extensive questionnaire. Patients had histological confirmation, clear bone destruction, a positive PET scan, and at least three minor criteria: progressive soft tissue mass, invasion of adjacent organs on follow-up CT or MRI, rising tumor markers, and typical appearance in cross-sectional imaging. Clinical or serological signs of inflammation were exclusion criteria. Initially 54% of the evaluated patients were N0, and the others were distributed evenly between N1 and N2; initial T stage was T1 in 2%, T2 in 24%, T3 in 60%, and T4 in 13%.

RESULTS

. Recurrent tumors were situated mainly in the posterior part of the bony pelvis. The pelvic side wall was a rare site of recurrence and involved in fewer than 5%. When abdominoperineal resection was compared to low anterior resection as primary operation, there was a significant difference in extension of recurrent tumors in the inferior parts of the pelvis; no significant differences were found in superior or lateral parts of the pelvis.

CONCLUSION

Because most tumor recurrences arise in the central pelvis, extending surgery to include dissecting the iliac vessels would probably offer only a moderate benefit, which must be balanced against potential side effects.

A randomised clinical trial of radiotherapy plus cisplatin versus radiotherapy alone in stage III non-small cell lung cancer

This study was designed to compare high-dose fractionated radiotherapy alone versus the same radiotherapy plus cisplatin in stage III non-small cell lung cancer (NSCLC). We randomly assigned 176 patients with stage III non-small cell lung cancer to one of two treatments; fractionated radiotherapy alone at dose of 64 Gy for 6-7 weeks (2 Gy given 32 times, in five fractions a week) or radiotherapy in the same schedule, combined with 20mg/m2 cisplatin 1 h before radiotherapy, given on days 1-5 of the second and sixth treatment weeks. The frequency of loco-regional progression was 68% among the patients who received radiotherapy plus cisplatin and 86% among those who received radiotherapy alone (P = 0.0001). The probability of survival free of disease after 3 years was 10% among the patients assigned to radiotherapy plus cisplatin and 0% among those treated only with radiotherapy (P = 0.0006). Overall survival at 3 years was 10% among those given radiotherapy plus cisplatin and 2% among those who received radiotherapy alone (P = 0.00001). Multivariate analysis demonstrated that radiotherapy plus cisplatin significantly improved loco-regional progression-free survival and overall survival, irrespective of radiation dose. The addition of cisplatin to fractionated radiotherapy prolongs loco-regional progression-free interval and survival in stage III non-small cell lung cancer.

Prognostic Significance of Apex Axillary Invasion for Locoregional Recurrence and Effect of Postmastectomy Radiotherapy on Overall Survival in Node-Positive Breast Cancer Patients

Postmastectomy irradiation substantially reduces the risk of locoregional recurrences (LRR) of breast carcinoma. However, debates continue on the prognostic factors for radiotherapy and the effect of radiotherapy on overall survival. The present study was undertaken to investigate the prognostic significance of level III positive nodes, along with the other factors for LRR, and to evaluate the effect of postmastectomy radiotherapy on overall survival among node-positive breast carcinoma treated systemically. Data from 549 consecutive node-positive breast cancer patients who underwent modified radical mastectomy and received adjuvant systemic therapy were studied retrospectively. Prognostic factors for LRR and the effect of postmastectomy radiotherapy on overall survival were analyzed. Survival curves were generated by the Kaplan-Meier method, and multivariate analysis was performed by the Cox proportional hazard model. The 5-year locoregional recurrence rate is 7%. Apical invasion was found to be an independent prognostic factor for LRR (HR 2.6, CI 1.29-5.35) along with a finding of 4 or more positive nodes and T3 tumor. Adjuvant radiotherapy decreased LRR and improved survival significantly. Apical invasion, 4 or more positive axillary lymph nodes, and T3 tumor are the predictors of LRR, and patients with these adverse factors are candidates for adjuvant radiotherapy. Postmastectomy radiotherapy improves overall survival.

Management of neuroendocrine liver metastases

BACKGROUND

The optimum management of neuroendocrine liver metastases, particularly the role of liver transplantation is ill-defined. Current strategies are based on anecdotal reports and small retrospective studies, rather than prospective data. This, as well as the failure to standardize treatment, has probably contributed to the reported variations in outcome.

DATA SOURCES

To formulate a putative management protocol and to reevaluate the role of liver transplantation in patients with neuroendocrine liver metastases, a review of the published literature (Medline search) was conducted.

CONCLUSIONS

Isolated hepatic metastases should be resected when suitable. Chemoembolization of liver metastases should precede resection of bulky disease and be used to palliate those with unresectable disease. Radiofrequency ablation is suitable for smaller metastatic lesions (<3 cm diameter) in the liver. Systemic treatment with somatostatin analogues or radioactive metaiodobenzylguanidine (MIBG) is appropriate to reduce symptoms and slow disease progression, but prospective data is required to define their exact roles as adjuvant and therapeutic agents. Although current systemic chemotherapy, applied in isolation, may have a role in patients in whom other therapies have failed, its efficacy remains unproven. Restriction of liver transplantation to the treatment of patients with carcinoid metastases with biologically favorable features, limited tumor bulk and without systemic disease may make transplantation a curative rather than a palliative treatment option in selected patients.

[Advance in diagnosis and management of local recurrent nasopharyngeal carcinoma]

Although radiotherapy is still the first measure of management of nasopharyngeal carcinoma and the curative effect is satisfactory at present, it is hard to avoid the recurrence of local-region in nasopharynx and/or neck lymph nodes in a part of patients after active treatment. Of them, the diagnosis and managements were difficult. This review analyzed the literatures of recent years. The factors of the recurrence, clinical characteristics, modern diagnosis technique and the salvage treatments of modern radiotherapy, chemotherapy, and surgery for recurrent nasopharyngeal carcinoma were introduced.

Multimodality Stereotactic Approach to the Treatment of Cystic Craniopharyngiomas

OBJECTIVES

To present the therapeutic reliability of a multimodality stereotactic approach (MSA) to cystic craniopharyngiomas (CPs), combining neuroendoscopy, intracavitary bleomycin and gamma knife (GK) radiosurgery.

METHODS

8 patients with mono- or multicystic CP (7/8 regrowths/recurrence) underwent stereotactic neuroendoscopy and subsequently treatment with intracavitary bleomycin and GK. They were clinically characterized by hypopituitarism (7 cases), visual impairment (7), endocranial hypertension (7), cognitive and behavioral disturbances (3), and cranial nerve deficits or focal signs (3). Concomitant hydrocephalus was observed in 3/8 patients. According to Backlund's classification, the treated CPs were classified as type A (3 cases), type Cc (4 cases) and type Dc (1 case). In all 8 patients, neuroendoscopy allowed evacuation of the cyst and, in multi-cystic CPs, fenestration of the interposed septa so as to create a single communicating cavity. Thus, a single catheter and Ommaya reservoir system was sufficient both for subsequent aspirations and for bleomycin injection (doses of 1.5-3 mg, usually repeated every 7-8 days, with total doses ranging from 3-35 mg). GK radiosurgery was carried out at a later stage on the collapsed cyst in type A forms, while in types Cc and Dc, it was used on the solid nodule on the same day as the neuroendoscopy.

RESULTS

The median follow-up period was 42.5 months. Neurological improvement was observed in 8/8 patients. A complete response (reduction of the entire tumor volume > 90 %) was observed in 3/8 cases (type A), a subtotal response (reduction > 50 %) in 4/8 cases (types Cc and Dc), and a partial response (reduction < 50 %) in 1/8 cases (type Cc). Treatment of CP alone led to normalization of the ventricular morphology in the 3 patients with associated hydrocephalus. Transient GK-related visual worsening was recorded in one case only. One patient died because of ventriculitis after repeated shunt replacements.

CONCLUSIONS

This MSA seems to be an effective and safe treatment alternative to microsurgery, above all in patients with regrowing/recurrent cystic CPs.

Die Wertigkeit der Melanomnachsorge aus der Patientenperspektive. Patients' view of melanoma follow-up

BACKGROUND

About 20% of melanoma patients develop progressive disease during follow-up. This is an alarming number for the patients. In view of new recommendations for melanoma follow-up, this study assesses the performance and quality of follow-up as perceived by the patients.

PATIENTS AND METHODS

A questionnaire was distributed to 462 patients with melanoma being followed in the skin cancer units of the universities of Cologne and Münster. Follow-up was based on recommendations published in 1994 by Malignant Melanoma Committee of the German Dermatological Society.

RESULTS

Follow-up was regularly performed. In Münster, 62% patients were seen in the university clinic, while in Cologne 53% of patients were followed jointly by the university clinic and practicing dermatologists. Radiological examinations were regularly repeated in 70% of the collective. 70% of patients reported performing self-examinations. 14% had developed progressive disease. 15% made use of psycho-social help.

CONCLUSIONS

The questionnaire reveals that the interdisciplinary follow-up and self-examinations proposed in the new recommendations are already well accepted. Based on latest standards, 90% of the patients felt that follow-up was reassuring. Psychosocial services should be offered more directly with emphasis on both social services and psychological support. Systematic patient inquiries can be used to establish quality standards for follow-up which are more patient-oriented.

Busulfan and cyclophosphamide as a conditioning regimen for pediatric acute lymphoblastic leukemia patients undergoing bone marrow transplantation

Bone marrow transplantation (BMT) has become the standard therapy for children with relapsed acute lymphoblastic leukemia. The authors report their experience with histocompatible BMT for 52 children with acute lymphoblastic leukemia conditioned with a non-total body irradiation (TBI) regimen using busulfan and cyclophosphamide (Bu/Cy). The efficacy and long-term toxicity of the Bu/Cy regimen were determined. Overall survival was 35%. One-year, 3-year, and 7-year event-free survival rates were 54%, 33%, and 23%, respectively. Of the 52 BMT recipients, 26 relapsed. Thirteen of the relapsed patients received a second BMT and three were surviving as of this writing. The most frequent cause of death was leukemia relapse. An initial remission duration of less than 18 months was a factor in decreasing the event-free survival. The Bu/Cy regimen was well tolerated, with minimal transplant-related mortality. Neurocognitive function was tested before BMT and 1 year after BMT. When 1-year posttransplant neurocognitive test scores were compared with pretransplant scores, there was no decrease. However, there was a significant decrease in the pretransplant neurocognitive test scores in BMT recipients compared with their normal siblings. The use of Bu/Cy as a conditioning regimen for BMT does not appear to affect posttransplant neurocognitive function. Other long-term side effects, such as endocrinopathies and secondary malignancies, were also minimal. These data show that the Bu/Cy regimen is well tolerated, but the overall survival rate remains low.

Results of treatment of retinoblastoma that has infiltrated the optic nerve, is recurrent, or has metastasized outside the eyeball

Since the development of chemotherapy regimens for patients with retinoblastoma started in the 1950s, various agents and regimens have been employed for various kinds of patients. Chemotherapy has been employed for: (1) patients with high-risk features for metastases, such as patients with optic nerve involvement, (2) patients with orbital involvement, and (3) patients with distant metastasis. Effective systemic chemotherapeutic agents include vincristine, doxorubicin, cyclophosphamide, etoposide, cisplatin, and carboplatin, and, as well, intrathecal agents, including methotrexate, cytarabine, and corticosteroids are available. With the addition of appropriate chemotherapies to the conventional treatment modalities such as enucleation and radiotherapy, patients with advanced retinoblastoma are expected to obtain a survival benefit. Moreover, a new modality combined with autologous stem cell support allowed us to use high-dose alkylating agents such as thiotepa, melphalan, and cyclophosphamide, which resulted in better prognosis for patients with metastatic retinoblastoma. Because of the small number of patients with retinoblastoma and the diversity of the disease characteristics in individual patients, there have been no clinical trials to determine whether to recommend a particular regimen, or to identify specific criteria in patients who would benefit from chemotherapy. Well-designed prospective controlled trials are warranted to establish a standard treatment strategy for patients with extraocular retinoblastoma.

Treatment and outcome of patients with chest wall recurrence after mastectomy and breast reconstruction

BACKGROUND

Chest wall recurrence (CWR) in the setting of previous mastectomy and breast reconstruction can pose complex management dilemmas for clinicians. We examined the impact of breast reconstruction on the treatment and outcomes of patients who subsequently developed a CWR.

METHODS

Between 1988 and 1998, 155 breast cancer patients with CWR after mastectomy were evaluated at our center. Of these patients, 27 had previously undergone breast reconstruction (immediate in 20; delayed in 7). Clinicopathologic features, treatment decisions, and outcomes were compared between the patients with and without previous breast reconstruction. Nonparametric statistics were used to analyse the data.

RESULTS

There were no significant differences between the reconstruction and no-reconstruction groups in time to CWR, size of the CWR, number of nodules, ulceration, erythema, and association of CWR with nodal metastases. In patients with previous breast reconstruction, surgical resection of the CWR and repair of the resulting defect tended to be more complex and was more likely to require chest wall reconstruction by the plastic surgery team rather than simple excision or resection with primary closure (26% [7 of 27] versus 8% [10 of 128], P = 0.013). Risk of a second CWR, risk of distant metastases, median overall survival after CWR, and distant-metastasis-free survival after CWR did not differ significantly between patients with and without previous breast reconstruction.

CONCLUSIONS

Breast reconstruction after mastectomy does not influence the clinical presentation or prognosis of women who subsequently develop a CWR. Collaboration with a plastic surgery team may be beneficial in the surgical management of these patients.

Successful unrelated cord blood transplantation following reduced-intensity conditioning for refractory acute myeloid leukemia

Patients with relapsed acute myeloid leukemia following autograft have a poor prognosis. The possibility of allograft is frequently time-limited, as the disease reappears before a stem cell donor can be found in the worldwide registries. Cord blood transplantation is a new therapeutic approach, since cord blood units are rapidly available. The authors show how a relapsed chemotherapy-refractory patient was successful transplanted with a mismatched cord blood unit after reduced-intensity conditioning. Twenty-three months after transplantation, the child is in continuous complete remission and has full donor chimerism and no signs of chronic graft-versus-host disease.

Role of ultrasonography in treatment selection

In spite of difficulties impacting objectivity and reproducibility due to its dependence on the technical and diagnostic ability of each examiner, ultrasonography (US) in general can evaluate very well soft tissue lesions, especially small lesions of 1 cm or less in size. US can reliably delineate the nature of several lesions, and can detect dilated mammary ducts and lymph nodes. On the other hand, US may miss ductal spread or lymph node metastasis of breast cancer, especially if the lesions are too minute to be detected by the instrument. US should be used together with X-ray or MR mammography to prevent false negative cases. US is useful for evaluating the local nature and characteristics of cancerous lesions such as size, invasiveness, histological type, intraductal spread etc, and can evaluate regional lymph node and liver metastasis for pre-treatment staging. In addition, US-guided techniques are essential for preoperative pathological diagnosis by FNAC or CNB and for marking the marginal line for partial mastectomy. US should be more actively used to monitor intra-mammary recurrence after breast conserving surgery.

FDG-PET delayed imaging for the detection of head and neck cancer recurrence after radio-chemotherapy: comparison with MRI/CT

In advanced head and neck cancer, an organ-sparing approach comprising radiation therapy combined with intra-arterial chemotherapy has become an important technique. However, the high incidence of residual masses after therapy remains a problem. In this study, we prospectively evaluated the use of 2-[18F]fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) delayed imaging for the detection of recurrence of head and neck cancer after radio-chemotherapy, and compared the FDG-PET results with those of magnetic resonance imaging (MRI) or computed tomography (CT). Forty-three lesions from 36 patients with head and neck cancer suspected to represent recurrence after radio-chemotherapy (median interval from therapy, 4 months) were studied. PET was performed at 2 h after FDG injection, and evaluated. The results were compared to those of contrast studies with MRI or CT performed within 2 weeks of the PET study, and to histological diagnosis (in all patients suspected of having recurrence) or clinical diagnosis. The lesion-based sensitivity (visual interpretation) and negative predictive value of FDG-PET (88% and 91%, respectively) were higher than those of MRI/CT (75% and 67% respectively). The specificity, accuracy and positive predictive value of FDG-PET (78%, 81% and 70%, respectively) were significantly ( P<0.05) higher than those of MRI/CT (30%, 47% and 39% respectively). Three of six patients with false positive findings had post-therapy inflammation. Receiver operating characteristic (ROC) analysis showed that retrospective evaluation with the standardised uptake ratio yielded the best results (sensitivity 87.5%, specificity 81.5%), followed by visual interpretation and then the tumour/neck muscle ratio. An FDG-PET delayed imaging protocol yielded significantly better results for the detection of recurrence of head and neck cancer after radio-chemotherapy than MRI/CT. Because of the high negative predictive value of FDG-PET (91.3%), if PET is negative, further invasive procedures may be unnecessary.

Anwendung komplementärer/alternativer Therapiemassnahmen bei Patientinnen mit Brustkrebs

BACKGROUND

Complementary/alternative medicine (CAM) is gaining increasing importance especially in the treatment of patients with breast carcinoma. The purpose of this analysis was to investigate the prevalence of CAM in patients with breast carcinoma, to statistically describe the preparations and therapies used, and to determine the reasons for their use, the source of information and the individual perception.

PATIENTS AND METHODS

The statements of 203 patients with breast carcinoma who underwent radiotherapy were analyzed. The median age was 54 years (range 38-77 years). All patients underwent surgery as first therapy. 36 patients received a second-line radiotherapy because of metastases (27 patients) or local recurrence (9 patients).

RESULTS

159 patients (78%) stated to carry out an additional treatment. 31 out of the 36 patients with metastases or local recurrence used CAM. Vitamin preparations (67%), mistletoe therapy (59%), and mineral preparations (33%) were used most frequently. 70% of the patients used a combination of two or more preparations/therapies. The most cited reason for using CAM was the aim of increasing quality of life (28%) and improving the immune system (27%). 72% stated an improvement of their individual perception. The main source of information was the general practitioner or the gynecologist.

CONCLUSION

The radiotherapist has to take these complementary/alternative therapies into consideration; their importance should be evaluated in further studies.

Management of recurrent locoregional breast cancer: oncologist survey

Locoregional recurrence (LRR) after therapy for early breast cancer is common. A questionnaire was used to assess consensus between breast oncologists about the definition, prognosis and management of patients with LRR. The questionnaire was mailed to surgical, radiation and medical oncologists in Canada, the UK and the USA. Of 495 questionnaires, 322 (65%) were returned. Most clinicians sampled agree that disease in the skin of the chest wall, surgical scar, axilla, ipsilateral breast tumor recurrence (IBTR), infraclavicular lymph nodes, supraclavicular fossa lymph nodes and internal mammary lymph nodes constitute sites of LRR. The sites that were felt to be curable by the majority of respondents were: IBTR, surgical scar, axilla or chest wall. It was for these disease sites that local therapy was generally recommended. Irrespective of the site of recurrence, most respondents surveyed recommend initiation of a new systemic therapy at the time of LRR. While the results of this survey show general agreement regarding the definition of sites of LRR, treatment recommendations vary among oncologists. Due to the variation in sites of recurrence, time since initial diagnosis and prior therapy, the exact prognosis and optimal management of LRR remain undefined. In the absence of randomized prospective trial data, recommendations for local and systemic therapy of LRR will continue to mimic those offered at the time of initial presentation of breast cancer.

Fully synthetic carbohydrate-based vaccines in biochemically relapsed prostate cancer: clinical trial results with alpha-N-acetylgalactosamine-O-serine/threonine conjugate vaccine

PURPOSE

We report the synthesis of a mucin-related O-linked glycopeptide, alpha-N-acetylgalactosamine-O-serine/threonine (Tn), which is highly simplistic in its structure and can induce a relevant humoral response when given in a trimer or clustered (c) formation. We tested for an antitumor effect, in the form of a change in the posttreatment versus pretreatment prostate-specific antigen (PSA) slopes, that might serve as a surrogate for effectiveness of vaccines in delaying the time to radiographic progression.

METHODS

We compared the antibody response to immunization with two conjugates, Tn(c)-keyhole limpet hemocyanin (KLH) and Tn(c)-palmitic acid (PAM) with the saponin immunologic adjuvant QS21, in a phase I clinical trial in patients with biochemically relapsed prostate cancer. Patients received Tn(c)-KLH vaccine containing either 3, 7, or 15 microg of Tn(c) per vaccination. Ten patients received 100 microg of Tn(c)-PAM. QS21 was included in all vaccines. Five vaccinations were administered subcutaneously during 26 weeks with an additional booster vaccine at week 50.

RESULTS

Tn(c), when given with the carrier molecule KLH and QS21, stimulated the production of high-titer immunoglobulin M (IgM) and IgG antibodies. Inferior antibody responses were seen with T(c)-PAM. There was no evidence of enhanced immunogenicity with increasing doses of vaccine. An antitumor effect in the form of a decline in posttreatment versus pretreatment PSA slopes was also observed.

CONCLUSION

A safe synthetic conjugate vaccine in a trimer formation was developed that can break immunologic tolerance by inducing specific humoral responses. It seemed to affect the biochemical progression of the disease as determined by a change in PSA log slope.