Neurolysis versus anterior transposition of the ulnar nerve in cubital tunnel syndrome: a 12 years single secondary specialist centre experience

BACKGROUND

Various conservative treatments and surgical techniques have been reported in the literature as efficient and feasible measures to treat the cubital tunnel syndrome. However, there has been no consensus on the best management of the syndrome, and uniform standardised guidelines have not yet been accepted or introduced. With our study, we present our experience on the clinical efficacies and outcomes of the surgical techniques of neurolysis alone and neurolysis associated with ulnar nerve anterior transposition at the elbow joint in patients with neuropathic symptoms due to cubital tunnel syndrome.

MATERIALS AND METHODS

A total of 107 patients with cubital tunnel syndrome were retrospectively enrolled, surgically treated and followed up in our study. The cohort was divided into two groups: 41 patients treated only with neurolysis of the ulnar nerve (Group 1), and 66 patients treated with neurolysis and anterior transposition (Group 2). Of the participants, 35 were women and 72 were men. The average age was 54 years. Significant comorbidities were preoperatively diagnosed in 26 patients. Conservative measures had been considered, followed by surgical management if appropriate. A pre-op electromyography was performed for all patients. All surgical procedures were performed by the same surgical team. A post-operative follow-up was carried out, and the findings were recorded. The "McGowan" and "Wilson and Krout" classifications and the DASH score were used. A satisfaction questionnaire was administered to all patients post-operatively at 2 weeks).

RESULTS

Ulnar nerve neurolysis and anterior transposition surgery were all successfully performed. Overall complications were post-operative haematoma (8%) and wound problems (5%). In 6% there was recurrence of symptoms. In 11% there was no improvement of symptoms. Pre-op McGowan classifications for groups 1 and 2 were 0% and 0% (grade 0), 21% and 24% (grade 1), 46% and 44% (grade 2), and 33% and 34% (grade 3), respectively. The post-op McGowan classifications were 34% and 37% (grade 0), 39% and 40% (grade 1), 23% and 20% (grade 2), and 4% and 3% (grade 3), respectively. The post-op Wilson and Krout classifications were 45% and 46% (excellent), 26% and 28% (good), 19% and 15% (fair), and 10% and 11% (poor), respectively. The DASH score means for groups 1 and 2 were 14.8 and 15.2, respectively. A negative Froment's sign was present in 73.2% and 71.2%, respectively. In Group 1, the post-op satisfaction questionnaire scores were 0 for one patient, 1 for four patients, 2 for seven patients, 3 for ten patients, 4 for twelve patients and 5 for seven patients. In Group 2, the post-op satisfaction questionnaire scores were 0 for three patients, 1 for nine patients, 2 for twelve patients, 3 for fifteen patients, 4 for eighteen patients and 5 for nine patients.

CONCLUSIONS

In our experience, the surgical technique to treat the cubital tunnel syndrome most efficiently and feasibly has not yet been established in terms of indications and outcomes. This is supported by the data present in the international literature. Good and similar results were obtained with neurolysis alone and neurolysis associated with anterior transposition of the ulnar nerve (in line with the international data). In conclusion, more high-quality studies of greater statistical power are needed to provide a consensus on the surgical indications and techniques to treat the cubital tunnel syndrome and to establish internationally standardised guidelines.

Role of Immunoscintigraphy in Clinical Assessment of Gastrointestinal Tumors

From June 1986 until April 1989 31 patients with gastrointestinal tumors were studied at follow-up for recurrences by Immunoscintigraphy (IS) using F(ab)2 fragments of monoclonal antibodies anti CEA and anti CA 19-9. IS was employed to confirm the presence of metastases already found (group A) and to verify metastases suspected following physical and Instrumental examinations and/or increases in CEA and/or CA 19-9 (group B). Thirty-four IS findings have been evaluated to date: 19 in group A, with 18 true positive and 1 false negative results; 15 in group B. In these patients there were 12 cases of pathologic high fixation: 6 were confirmed using standard examinations after a median follow-up of 1 month (range 1-12); 6 cases had no metastatic evolution at the suspected site after a follow-up of 5-28 months. In 3 cases IS was negative, these patients are disease free at 13, 14 and 24 months. In group B, 5 of 8 abdominal intense fixations were early diagnoses of local or peritoneal recurrences. The overall accuracy was 79.4% and it was not affected by circulating CEA levels; sensitivity was 96%. IS can be considered useful as a primary diagnostic examination in the follow-up of patients with suspected abdominal metastases.

Association of IL-8 and eNOS polymorphisms with clinical outcomes in bevacizumab-treated breast cancer patients: an exploratory analysis

BACKGROUND

The role of bevacizumab in metastatic breast cancer is controversial. Identification of predictive biomarkers could help to select patients who really benefit from it. We evaluated the association of angiogenesis-related gene polymorphisms with the treatment outcome of bevacizumab in metastatic breast cancer patients.

PATIENTS AND METHODS

eNOS-786T/C and -894G/T, IL-8-251T/A genomic polymorphisms were assessed in 31 metastatic breast cancer patients treated with bevacizumab plus chemotherapy in the first-line setting. Testing for association between each polymorphism and treatment outcome was performed.

RESULTS

Patients with IL-8 251 AA genotype showed a significantly lower progression-free survival in each combination comparison: "TT" vs "AA" (13 vs 8 months; p = 0.008); TT vs TA vs AA (13 vs 11 vs 8 months; p = 0.02); TT vs TA +AA (13 vs 11 months; p = 0.01); TT + TA vs AA (12 vs 8 months; p = 0.01) and a lower overall survival when compared with TT +TA genotype (26 vs 51 months, p = 0.04). Patients carrying eNOS 894 TT genotype showed a statistically significant lower progression-free survival than patients with GG genotype (11.5 vs 26.5 months; p = 0.04) with no differences in the overall survival. No association with response rate was found with any of the polymorphisms analyzed.

CONCLUSION

These findings suggest that IL-8 251T/A and eNOS-894 G/T polymorphisms might have a role in predicting treatment outcome of bevacizumab in metastatic breast cancer. Our results are hypothesis generating and need to be confirmed in larger clinical trials.

ERCC1 Induction after Oxaliplatin Exposure May Depend on KRAS Mutational Status in Colorectal Cancer Cell Line: In Vitro Veritas

Introduction: Oxaliplatin (Oxa) is widely used in metastatic colorectal cancer (mCRC), but currently there are not valid predictors of response to this drug. In the control arms both of OPUS and PRIME studies Oxa seems more active in patients with mCRC with mutated (mt) KRAS than in those with wild type (wt) KRAS. Recently we have retrospectively confirmed this suggestion, therefore we have hypothesized that the mutational status of KRAS could influence the expression of ERCC1, one of the main mechanisms of Oxa resistance.

Material and Methods: We used four cell lines of colorectal cancer: two KRAS wild type (wt) (HCT-8 and HT-29) and two KRAS mt (SW620 and SW480). We evaluated the sensitivity of these cell lines to Oxa by MTT-test as well the ERCC1 levels before and after 24 h exposure to Oxa by Real-Time PCR. We silenced KRAS in a KRAS mt cell line (SW620LV) to evaluate the impact on Oxa sensitivity and ERCC1 levels. Lastly, ERCC1 was also silenced in order to confirm the importance of this protein as an Oxa resistance factor.

Results: The KRAS mt cell lines resulted more sensitive to Oxa (OR 2.68; IC 95% 1.511-4.757 p<0.001). The basal levels of ERCC1 did not show significant differences between KRAS mt and wt cell lines, however, after 24 h exposure to Oxa, only the wt KRAS lines showed the ability to induce ERCC1, with a statistically significant difference (OR 42.9 IC 95% 17.260-106.972 p<0.0005). By silencing KRAS, sensitivity to Oxa was reduced in mt KRAS cell lines and this effect was associated with the acquisition of ability to induce ERCC1. Silencing of ERCC1, in turn, enhanced the sensitivity to Oxa in wt KRAS cell lines and restored sensitivity to Oxa in SW620LV cell line.

Conclusion: KRAS mutated cell lines were more sensitive to Oxa. This feature seems secondary to the inability of these cells to induce ERCC1 after exposure to Oxa. Thus, KRAS mutational status might be a predictor of response to Oxa in CRC surrogating the cell ability to induce ERCC1.

Anti-tumour and anti-angiogenetic effects of zoledronic acid on human non-small-cell lung cancer cell line

OBJECTIVES

Although emerging data suggest that zoledronic acid (Zol) may have different anti-tumour activities against a broad range of cancers, its effects on lung cancer remain largely unknown. The aim of this study was to evaluate in vitro the anti-tumoural and anti-angiogenetic effect of zoledronic acid in non-small-cell lung cancer (NSCLC) cells.

MATERIAL AND METHODS

We treated A549 NSCLC cells with zoledronic acid to investigate survival, cell cycle activity, anti-angiogenic activity and apoptotic responses to it.

RESULTS

We observed that highest Zol concentration (100μm) caused arrest in G1 phase of the cell cycle and also induced different percentages of apoptosis in presence (0.9% versus 4.4%) or absence (2.4% versus 28.5%) of serum (P=0.0001). Zol concentration from 5 to 100μm for 2 days induced significant concentration-dependent cell death in adherent cells. Furthermore, Zol (10-100μm) induced dose-dependent reduction both of mRNA and protein expression of VEGF associated with parallel decrease in VEGF secretion in the culture medium.

CONCLUSION

Taken together, these results support a possible anti-cancer and anti-angiogenetic activity of Zol. Our data may not only provide a basis for the clinical use of this drug as preventive agent of bone metastases but also suggest that Zol deserves attention as an anti-cancer agent in non-small-cell lung cancer.

Gas in portal circulation and pneumatosis cystoides intestinalis during chemotherapy for advanced rectal cancer

OBJECTIVES

Acute abdominal symptoms with CT scan evidence of intramural gas in bowel walls (pneumatosis cystoides intestinalis, PCI) and of gas in the portal venous blood (PBG) in patients undergoing chemotherapy may represent a worrisome picture, suggestive of bowel necrosis. This picture remains a major clinical clue and the reporting of new cases may help to share awareness and experience on management. We describe a patient with acute abdominal symptoms and evidence of PCI with PBG under cetuximab, oxaliplatin, tegafur-uracil and folinic acid chemotherapy for metastatic adenocarcinoma of the rectosigmoid junction.

METHODS

After admission for mucositis with diarrhea and profound dehydration, and subsequent emergency laparotomy for derotation of an intestinal volvulus, on the tenth postoperative day the patient developed fever and abdominal pain, with CT scan evidence of PCI with PBG. The exam of the abdomen did not suggest major problems requiring emergency surgery, and antibiotic treatment with close monitoring were performed, followed by rapid improvement.

RESULTS

Twelve days later, after resumption of oral diet, the patient unexpectedly suffered a spontaneous jejunal microperforation, requiring emergency laparotomy and bowel resection. Pathology showed that the perforation was within an area of ulceration involving the inner superficial layer of the bowel. Subsequently recovery was normal and at present, after 15 months, the patient is well and continuing chemotherapy.

CONCLUSIONS

This is probably the first report of PCI with PBG related to intestinal toxicity during cetuximab, oxaliplatin, tegafur-uracil and folinic acid chemotherapy in a patient with advanced rectal carcinoma, followed by delayed small bowel perforation. It provides an example of the challenges involved in the management of this type of patient.

Final analysis of colorectal cancer patients treated with irinotecan and 5-fluorouracil plus folinic acid neoadjuvant chemotherapy for unresectable liver metastases

We have previously reported that neoadjuvant therapy with modified FOLFIRI enabled nearly a third of patients with metastatic colorectal cancer (mCRC) to undergo surgical resection of liver metastases. Here, we present data from the long-term follow-up of these patients. Forty patients received modified FOLFIRI: irinotecan 180 mg m(-2), day 1; folinic acid, 200 mg m(-2); and 5-fluorouracil: as a 400 mg m(-2) bolus, days 1 and 2, and a 48-h continuous infusion 1200 mg m(-2), from day 1. Treatment was repeated every 2 weeks, with response assessed every six cycles. Resected patients received six further cycles of chemotherapy postoperatively. Nineteen (47.5%) of 40 patients achieved an objective response; 13 (33%) underwent resection. After a median follow-up of 56 months, median survival for all patients was 31.5 months: for non-resected patients, median survival was 24 months and was not reached for resected patients. Median time to progression was 14.3 and 5.2 months for all and non-resected patients, respectively. Median disease-free (DF) survival in resected patients was 52.5 months. At 2 years, all patients were alive (8 DF), and at last follow-up, eight were alive (6 DF). Surgical resection of liver metastases after neoadjuvant treatment with modified FOLFIRI in CRC patients achieved favourable survival times.

Long-term follow-up of colorectal cancer (CRC) patients treated with neoadjuvant chemotherapy with irinotecan and fluorouracil plus folinic acid (5-FU/FA) for unresectable liver metastases

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Background: In a prospective study, neoadjuvant therapy with irinotecan and 5-FU/FA (modified FOLFIRI) enabled a significant proportion of CRC patients (pts) with initially unresectable liver metastases (LM) to undergo potentially curative surgical resection (Annals of Oncology 15:933–939, 2004). Here we report data on survival and time to progression (TTP) from long-term follow-up. Methods: Forty patients received irinotecan 180 mg/m2 IV on day 1, FA 200 mg/m2 IV on days 1 and 2, 5-FU IV bolus 400 mg/m2 on days 1 and 2, and 5-FU 48-h continuous IV infusion 1200 mg/m2 on day 1. Treatment was repeated every 2 wks, with response assessed every 12 wks (6 cycles), and continued until an objective response (OR), indicating suitability for surgery, disease progression, or unacceptable toxicity. Pts undergoing liver resection received a further 6 cycles postoperatively. Results: Nineteen (47.5%) of 40 pts had OR; 13 (33%) underwent resection. Treatment was well tolerated, with adverse events typical of agents used. As of June 30, 2005, median follow up was 30.4 months (mo). Median survival for all pts was 30.1 mo; median survival in nonresected pts was 24 mo, and overall survival (OS) in resected pts was not reached. TTP was 14.3 mo for all pts and 5.2 mo for nonresected pts. Disease-free (DF) survival in resected pts was 28.2 mo. Of resected pts, all were alive and 9 were DF at 1 y, all were alive and 6 were DF at 2 y, and 9 were alive and 6 DF at last follow-up. Conclusion: Surgical resection of LM after neoadjuvant treatment with modified FOLFIRI in CRC pts was followed by favorable DF and OS times. These data encourage use of irinotecan in pts with unresectable LM. Forthcoming studies should include arms with irinotecan-based combination regimens.

[Table: see text]

Bolus and infusional 5-fluorouracil combined with cisplatin in advanced gastric cancer

5-Fluorouracil (5-FU) is the main drug used in the treatment of advanced gastric cancer. Combination chemotherapy is not always superior to 5-FU alone, especially when biomodulators are also administered. In an attempt to exploit all the cytotoxic mechanisms of 5-FU, we carried out a pilot study with a double route of administration of 5-FU (intravenous bolus and continuous infusion) and a multiple modulation of 5-FU by methotrexate (MTX), 6S-leucovorin (6S-LV) and cisplatin (CDDP). A group of 30 patients affected by advanced gastric cancer was treated with MTX 50 mg/m2 and 5-FU 400 mg/m2 as an i.v. bolus on day 1, followed by a 5 day i. v. continuous infusion of 5-FU 600 mg/m2/day and 6S-LV 100 mg/m2/day; on day 3 CDDP 100 mg/m2 was also administered. The regimen was repeated every 4 weeks. Six partial responses (20+/-14. 3%), 12 stable diseases (40+/-17.5%) and 12 progression (40+/-17.5%) were observed in an intent-to-treat analysis. Median survival was 7 months. All responding patients had performance status 0-1. Grade 3-4 toxicity was mainly gastrointestinal, but grade 3-4 anemia and leucopenia were also recorded. The schedule has low activity. The use of different modulators and way of administration of 5-FU does not provide advantages in advanced gastric cancer.

Vinorelbine and alternating cisplatin and ifosfamide in the treatment of non-small cell lung cancer

In order to explore the activity of a combination of vinorelbine (VNL) and alternating cisplatin (CDDP) and ifosfamide (IFX) in non-small cell lung cancer (NSCLC), a phase II study was performed. Seventy chemoradiotherapy naive patients with NSCLC, stage IIIA, IIIB and IV disease, PS (ECOG) </=2, were treated with CDDP 40 mg/m(2) on days 1, 2, 3, IFX 1,800 mg/m(2) on days 22, 23, 24 and VNL 30 mg/m(2) on days 1, 8, 22, 29 every 6 weeks up to 6 courses. In the 67 evaluable patients, an objective response rate was observed in 47.8 +/- 12% (95% CI) with complete responses in 6%; responses occurred more frequently in patients with locally advanced disease (stage IIIA/IIIB) and/or performance status 0. The median duration of survival was 12 months: 19.9 months in stage III patients who received an integrated treatment and 10 months in metastatic disease. The median time to treatment failure was 10.5 months. Toxicity was mainly hematological, even though it was not dose-limiting and easily manageable. This combination seems to be active, and the good safety profile is probably the result of the use of an alternating schedule of CDDP and IFX. Median overall survival was also encouraging in stage IV disease. The prolongation of survival obtained when surgery and/or radiotherapy is applicable needs confirmation through a larger study.

Treatment of patients with advanced gastric carcinoma with a 5-fluorouracil-based or a cisplatin-based regimen: two parallel randomized phase II studies

BACKGROUND

Although many drug combination therapies have been proposed, there is no standard therapy for patients with advanced gastric carcinoma. The superiority of combination therapy over monochemotherapy has not been demonstrated convincingly. To explore the role of monochemotherapy, the authors evaluated 5-fluorouracil (5-FU), modulated by 6S-leucovorin (6S-LV) and a cisplatin-containing regimen, which was comprised of epirubicin, etoposide, and cisplatin with the addition of the reversal agent lonidamine (EEP-L).

METHODS

After stratification according to performance status (PS) and resection of the primary tumor, 72 patients with advanced gastric carcinoma were randomized to 2 parallel Phase II trials with 5-FU/6S-LV and EEP-L, respectively. Thirty-six patients in Study A received bolus 6S-LV, 100 mg/m2, followed by bolus 5-FU, 370 mg/m2, on Days 1-5 and 36 others in Study B received epirubicin, 30 mg/m2, on Days 1 and 5; etoposide, 100 mg/m2, on Days 1, 3, and 5; cisplatin, 30 mg/m2, on Days 2 and 4; and lonidamine, 150 mg/day.

RESULTS

There were 6 partial responses (18.2%) (95% confidence interval [CI] +/- 13.2) in Study A and 7 partial responses (21.9%) (95% CI +/- 14.3) in Study B. Partial responses were more frequent in patients with resected tumors or with an Eastern Cooperative Oncology Group PS of 0-1. The median duration of response was 8.8 and 8.3 months, respectively, in Study A and Study B. The median survival reached 8 months in Study A and 9 months in Study B. In the whole population of patients survival was significantly higher in patients with a PS of 0-1 (P < 0.05). Patients with a PS of 0-1 and a resected tumor had the significantly longest survival both in EEP-L treated patients and in all evaluable patients in the two studies. The most frequent World Health Organization Grade 3-4 toxic effects were gastrointestinal in Study A and hematologic in Study B. No treatment-related death was observed.

CONCLUSIONS

The efficacy of 5-FU, modulated with 6S-LV, is moderate in patients with advanced gastric carcinoma, similar to cisplatin-containing regimens. PS and other prognostic factors could influence the response rate, which does not appear to be a reliable parameter for evaluating the outcome of chemotherapy trials.

Risk factors for intrahepatic recurrence of hepatocellular carcinoma in cirrhotic patients treated by percutaneous ethanol injection

BACKGROUND

Hepatocellular carcinoma (HCC) complicating cirrhosis has a high intrahepatic recurrence rate after treatment by surgical resection or percutaneous ethanol injection (PEI). In this study, certain clinical, biochemical, and pathologic parameters were evaluated as risk factors for intrahepatic tumor recurrence in liver segments different from that of the first neoplasm in a group of 57 cirrhotic patients with single HCC < 5 cm treated by PEI.

METHODS

After PEI treatment of HCC, the patients were followed for a mean period of 33 +/- 16 months. The following pretreatment parameters were evaluated as predictors of tumor recurrence: age, gender, Child-Pugh score, hepatitis B virus surface antigen, hepatitis C virus antibodies, alanine aminotransferase, aspartate aminotransferase, alpha-fetoprotein (AFP) level before PEI, alcohol abuse, HCC size, HCC ultrasound pattern, HCC histologic grade, HCC capsule, and time from cirrhosis diagnosis. Furthermore, the posttreatment parameters of the AFP level 1 month after PEI and recurrence of HCC in the same liver segment were also evaluated.

RESULTS

The cumulative 4-year intrahepatic recurrence rate of HCC was 62%. The log rank test indicated that, among pretreatment parameters, time from cirrhosis diagnosis > 6 years (P = 0.05) and AFP level before PEI of > 25 ng/mL (P = 0.00005) were significantly linked to tumor recurrence. Cox's proportional hazards model showed that only AFP level before PEI was independently associated with recurrence (P < 0.002). With regard to posttreatment parameters, an AFP level 1 month after PEI of > 13 ng/mL was shown to be significantly related to tumor recurrence by the log rank test (P < 0.0001).

CONCLUSIONS

Cirrhotic patients with single HCC treated by PEI who have slightly increased serum levels of AFP before and/or after PEI treatment are at increased risk of intrahepatic tumor recurrence and should undergo a close follow-up program.

Risk factors for intrahepatic recurrence of hepatocellular carcinoma in cirrhotic patients treated by percutaneous ethanol injection

BACKGROUND

Hepatocellular carcinoma (HCC) complicating cirrhosis has a high intrahepatic recurrence rate after treatment by surgical resection or percutaneous ethanol injection (PEI). In this study, certain clinical, biochemical, and pathologic parameters were evaluated as risk factors for intrahepatic tumor recurrence in liver segments different from that of the first neoplasm in a group of 57 cirrhotic patients with single HCC < 5 cm treated by PEI.

METHODS

After PEI treatment of HCC, the patients were followed for a mean period of 33 +/- 16 months. The following pretreatment parameters were evaluated as predictors of tumor recurrence: age, gender, Child-Pugh score, hepatitis B virus surface antigen, hepatitis C virus antibodies, alanine aminotransferase, aspartate aminotransferase, alpha-fetoprotein (AFP) level before PEI, alcohol abuse, HCC size, HCC ultrasound pattern, HCC histologic grade, HCC capsule, and time from cirrhosis diagnosis. Furthermore, the posttreatment parameters of the AFP level 1 month after PEI and recurrence of HCC in the same liver segment were also evaluated.

RESULTS

The cumulative 4-year intrahepatic recurrence rate of HCC was 62%. The log rank test indicated that, among pretreatment parameters, time from cirrhosis diagnosis > 6 years (P = 0.05) and AFP level before PEI of > 25 ng/mL (P = 0.00005) were significantly linked to tumor recurrence. Cox's proportional hazards model showed that only AFP level before PEI was independently associated with recurrence (P < 0.002). With regard to posttreatment parameters, an AFP level 1 month after PEI of > 13 ng/mL was shown to be significantly related to tumor recurrence by the log rank test (P < 0.0001).

CONCLUSIONS

Cirrhotic patients with single HCC treated by PEI who have slightly increased serum levels of AFP before and/or after PEI treatment are at increased risk of intrahepatic tumor recurrence and should undergo a close follow-up program.

Risk factors for intrahepatic recurrence of hepatocellular carcinoma in cirrhotic patients treated by percutaneous ethanol injection

BACKGROUND

Hepatocellular carcinoma (HCC) complicating cirrhosis has a high intrahepatic recurrence rate after treatment by surgical resection or percutaneous ethanol injection (PEI). In this study, certain clinical, biochemical, and pathologic parameters were evaluated as risk factors for intrahepatic tumor recurrence in liver segments different from that of the first neoplasm in a group of 57 cirrhotic patients with single HCC < 5 cm treated by PEI.

METHODS

After PEI treatment of HCC, the patients were followed for a mean period of 33 +/- 16 months. The following pretreatment parameters were evaluated as predictors of tumor recurrence: age, gender, Child-Pugh score, hepatitis B virus surface antigen, hepatitis C virus antibodies, alanine aminotransferase, aspartate aminotransferase, alpha-fetoprotein (AFP) level before PEI, alcohol abuse, HCC size, HCC ultrasound pattern, HCC histologic grade, HCC capsule, and time from cirrhosis diagnosis. Furthermore, the posttreatment parameters of the AFP level 1 month after PEI and recurrence of HCC in the same liver segment were also evaluated.

RESULTS

The cumulative 4-year intrahepatic recurrence rate of HCC was 62%. The log rank test indicated that, among pretreatment parameters, time from cirrhosis diagnosis > 6 years (P = 0.05) and AFP level before PEI of > 25 ng/mL (P = 0.00005) were significantly linked to tumor recurrence. Cox's proportional hazards model showed that only AFP level before PEI was independently associated with recurrence (P < 0.002). With regard to posttreatment parameters, an AFP level 1 month after PEI of > 13 ng/mL was shown to be significantly related to tumor recurrence by the log rank test (P < 0.0001).

CONCLUSIONS

Cirrhotic patients with single HCC treated by PEI who have slightly increased serum levels of AFP before and/or after PEI treatment are at increased risk of intrahepatic tumor recurrence and should undergo a close follow-up program.

Prognostic significance of cytoplasmic p53 overexpression in colorectal cancer. An immunohistochemical analysis

p53 overexpression was studied by immunohistochemistry in 96 consecutive colorectal cancer patients, subdividing positive specimens according to two staining patterns: cytoplasmic or nuclear. Forty-seven per cent of the cases were p53 positive, a significant correlation being found with Dukes' stage (P = 0.0036). A prevalence of nuclear staining was observed in Dukes' B and cytoplasmic in Dukes' D stages. After 36 months, 23% of the patients had a recurrence, and 45% were p53 positive, all Dukes' C-D stage with cytoplasmic staining. The Kaplan-Meier curve showed a significant correlation between p53 cytoplasmic staining and disease-free survival period (P = 0.002). With respect to disease-free survival, the Cox proportional hazard regression test, comparing p53 positivity with Dukes' stage, showed the latter to be the most significant variable. In our series of patients, advanced Dukes' stage tumours were localised in the right colon, where a higher percentage of p53 positivity (67% versus 40% of the left side), as well as a higher frequency of cytoplasmic staining was observed. In conclusion, from the data obtained, a strong correlation between p53 cytoplasmic staining and patient prognosis is clearly indicated.

Effect of cisplatin in advanced colorectal cancer resistant to 5-fluorouracil plus (S)-leucovorin

Modulation of 5-fluorouracil (5-FU) is currently being investigated in advanced colorectal cancer. In an attempt to improve the results obtainable for the association of 5-FU and leucovorin, we decided to add cisplatin to 5-FU and (6S)-leucovorin (S-LV) after disease progression. The hypothesis was that a pharmacological enhancement of the efficacy of 5-FU would result in responses in 5-FU-unresponsive patients or in a second response in previously responding patients. A group of 28 5-FU+S-LV-pretreated patients, with advanced measurable colorectal cancer, were treated with 80 mg/m2 cisplatin on day 1, 80 mg/m2 S-LV and 370 mg/m2 5-FU as an i. v. bolus for 5 consecutive days every 4 weeks. We obtained 3 partial responses (response rate: 11 +/- 11%), while 11 patients had stable disease (39 +/- 18%). Among the 3 responders, 1 patient had earlier achieved a partial response, a second stable disease and 1 had disease progression after the previous 5-FU+S-LV treatment. The median survival time for all 28 patients was 11 months. Toxicity was minimal and consisted of mild and reversible gastrointestinal symptoms and myelosuppression. We believe that further studies must be carried out to establish the real impact of the synergism between cisplatin, 5-FU and S-LV in untreated patients.

[Treatment of gastrointestinal non-Hodgkin's lymphoma]

Primary gastrointestinal Lymphoma is a relatively infrequent tumor, who could be effectively treated with both surgery and chemotherapy or radiotherapy. The design of treatment depends on prognostic factors, namely stage and histologic grade. The most functional staging system seems that of Mushoff, while the recent concept of "Mucosa-associated lymphoid tissue" has allowed to correlate the histologic grading with prognosis. Surgery is the most used therapeutic approach in IE and IIE stages, but both chemotherapy and radiotherapy or their combination seem to have similar activity. Adjuvant chemo- and/or radio-therapy after surgery increases survival compared to surgery alone. Chemotherapy is the treatment of choice in more advanced stages.

Advanced non-small-cell lung cancer (NSCLC) treated with folinic acid (F), fluorouracil (FU), vincristine (O), and mitomycin-C (Mi), (F-FOMi)

Thirty-one patients with advanced non-small-cell lung cancer (NSCLC) were treated with a combination of folinic acid, fluorouracil, vincristine, and mitomycin (F-FOMi). Eight partial responses (26%), eight stable disease (26%), and 15 progressive disease (48%) were obtained. Patients with performance status (PS) 0-1 had a significantly better response rate than those with PS 2-3. Overall actuarial survival was 10 months. Toxicity was mild and mainly gastrointestinal with mucositis and diarrhea. F-FOMi seems to be comparable to regimens more widely used in the treatment of NSCLC.

Salvage chemotherapy with mitoxantrone and mitomycin with or without methotrexate in advanced breast cancer

Thirty-three patients with advanced and refractory breast cancer were treated with two mitoxantrone-containing regimens (mitoxantrone plus mitomycin and mitoxantrone plus mitomycin plus methotrexate). All patients had received previous chemotherapy with cyclophosphamide, methotrexate and fluorouracil (CMF); cyclophosphamide, adriamycin and fluorouracil (CAF); or CMF and CAF. Partial response occurred in five patients (15 +/- 12%), stable disease occurred in 15 patients (45 +/- 17%) and progressive disease occurred in 13 patients (40 +/- 17%). The median duration of response was 5 months. The median actuarial survival was 11 months. Toxicity was mild, even in patients who had previously received anthracyclines; generally it was mainly hematological. We thus recommend mitoxantrone-containing regimens as salvage chemotherapy in advanced breast cancer.

Antipyrine metabolism in patients with liver metastases from colorectal cancer

BACKGROUND

The influence of cancer on antipyrine metabolism is under debate.

METHODS

To assess the functional activity of a liver with solid metastases from primary colorectal cancer, antipyrine metabolism was studied after the drug was administered orally (18 mg/kg body weight) to 55 healthy volunteers, 62 patients with well-compensated cirrhosis, and 42 patients with small (Class A) or massive (Class B) metastatic liver involvement.

RESULTS

In patients with cancer, antipyrine clearance (0.472 +/- 0.177 ml/min/kg) was similar to that in healthy volunteers (0.456 +/- 0.198 ml/min/kg) and significantly higher than in those with cirrhosis (0.259 +/- 0.17 ml/min/kg, P less than 0.001). There was no difference in antipyrine pharmacokinetics between Class A and B involvement. In the entire population, antipyrine clearance was correlated with serum albumin levels (r = 0.294, P = 0.0002) and prothrombin activity (r = 0.416, P = 0.001). This positive correlation was not present when only the neoplastic group was considered. No correlation was found between antipyrine clearance and alkaline phosphatase levels. In patients with cancer, no relationship was found between antipyrine clearance and carcinoembryonic antigen and lactic dehydrogenase levels.

CONCLUSIONS

These results show that patients with livers largely replaced by solid metastases are able to metabolize antipyrine to the same extent as healthy subjects.

Delayed hypersensitivity to 6-methyl-prednisolone in Henoch Schöenlein syndrome

We report a case of allergic reaction to oral 6-methyl-prednisolone in a patient with Henoch Schöenlein syndrome. When this syndrome was first diagnosed the patient was started on 6-methyl-prednisolone orally and after 4 days he developed a pruriginous generalized maculo-papular eruption. The rash disappeared 1 week after withdrawal of 6-methyl-prednisolone. The skin tests performed 1 month after with main food allergens were negative. Patch test with 0.10 ml of solution containing 6-methyl-prednisolone 40 mg/ml was positive after 48 and 72 h. The cutaneous biopsy on the patch tested skin revealed a perivascular infiltrate of lymphocytes, histiocytes and eosinophils.

Hepatocarcinoma in cirrhosis. Is antithrombin III a neoplastic marker?

It has been reported that hepatoma (HCC) cells produce abnormal proteins such as erytropietin, fibrinogen, prothrombin, and, recently, antithrombin III (AT III). In a preliminary report, we reported increased AT III levels in patients bearing HCC independent of their clinical liver status. The present study was performed to assess antithrombin III levels and other serological data present in patients with cirrhosis and in patients with cirrhosis and clinical findings of neoplastic disease. In 70 well-matched patients (47 with cirrhosis and 23 with cirrhosis and proven HCC) serum total cholesterol, albumin, prothrombin, alkaline phosphatase, AFP, aminotransferases, and AT III were determined. Together with AFP and alkaline phosphatase, patients with HCC had higher values of AT III (88 +/- 7%) and total cholesterol (184 +/- 17 mg/100 ml), as compared with cirrhotic patients (AT III 56 +/- 3.6%; total cholesterol 113 +/- 5 mg/100 ml) (P less than 0.001). No difference was observed between these two groups for albumin, prothrombin, and aminotransferases. In HCC patients, AT III levels were related to the total cholesterol level (R2 = 0.317), whereas in the cirrhotic patients it correlated with the prothrombin level (R2 = 0.274). These data suggest that in HCC patients a greater rate of synthesis of AT III occurs, whereas in cirrhotic patients lower levels of AT III occur due to impaired synthesis or increased catabolism of the protein. The serial determination of AT III in cirrhotic patients as a means of detecting neoplastic transformation is suggested.

5-Fluorouracil (FU) with folinic acid (FA) and mitomycin C (MMC) in the adjuvant treatment of colorectal carcinoma. Part I. Evaluation of toxicity

Ninety-six patients with colorectal cancer (stage B2-C) were randomized to the control arm or to receive adjuvant chemotherapy with folinic acid, FU and MMC. Ninety-three patients are evaluable. The median follow up is 12 months. The average time between surgery and the start of therapy is 28 days. Toxicity is evaluable in 36 of 41 treated patients. Four patients (10%) failed to complete the projected treatment due to toxicity. Toxicity observed in 208 courses of therapy was mostly gastrointestinal and hematological. No cases of treatment related death or cancer-associated hemolytic uremic syndrome (C-HUS) were reported. The average relative dose intensity (rDI) of the projected treatment was 82.6%. Our study is ongoing and further patients are required to achieve statistically significant results.

Association of epirubicin, etoposide and cisplatin in gastric cancer. A phase II study

Cisplatin-based drug combinations are now currently investigated in an attempt to surpass the results obtainable by 5-FU alone or by 5-FU-containing regimens. We evaluated 29 patients with advanced and measurable gastric adenocarcinoma treated with etoposide, epirubicin and cisplatin. One patient had complete response (3 +/- 7%); 9 patients had partial response (31 +/- 17%); 5 patients (17 +/- 14%) were considered stable (S) and 14 (48 +/- 18%) were classified as progressive. The average survival time for the entire group was 11 months with 25% of the patients alive at 24 months. We feel that cisplatin-containing regimens are promising and deserve further investigations. To clearly explore the potential innovative role of these regimens randomized trials versus FAM or 5-FU alone are mandatory.

Advanced colon cancer: staging and prognosis by CEA test

The carcinoembryonic antigen (CEA) test was studied in 54 patients with advanced stages of colon cancer which was treated with high doses of folinic acid + fluorouracil. The CEA test correlates evaluated included: prognostic value, performance status, metastatic pattern, histologic grading, predictive value for response to chemotherapy, and value differences in cases with partial response to therapy. CEA levels less than 5 ng/ml corresponded to a greater survival time than did levels greater than 5 ng/ml. A correlation of CEA with performance status and with metastatic pattern was demonstrated. A progressive increase in average CEA values corresponded to increases in neoplastic mass. Although CEA levels were not found to be an index for predicting the response to chemotherapy, there was a significant different between pre- and posttreatment levels for partial response. The results suggest that CEA offers an additional criterion for evaluating the response of colon cancer to chemotherapy and it also has a role in the staging of advanced disease.

A response in advanced post-menopausal breast cancer during treatment with the luteinising hormone releasing hormone agonist--Zoladex

Luteinising hormone releasing hormone (LHRH) agonists are currently undergoing clinical trials in the treatment of advanced breast cancer in pre-menopausal women. Clinical responses are attributed to the suppression of the pituitary-ovarian axis, with a reduction in circulating levels of gonadal steroids similar to that produced by castration. In the present case report, we report a partial response to a LHRH analogue in a post-menopausal woman refractory to other endocrine treatments. This response cannot be explained with a chemical castration and confirms the possible direct anti-tumor effect of Zoladex.

High-dose folinic acid (HDFA) combined with 5-fluorouracil (5-FU) in first line chemotherapy of advanced large bowel cancer

The therapeutic activity of 5-FU in large bowel cancer is enhanced by increasing the intracellular pool of reduced folates. We treated 45 patients with advanced colon cancer with HDFA and 5-FU for 5 consecutive days. None had been given previous radio- or chemotherapy. All had measurable disease. Not one complete response was observed. Thirteen of the 39 evaluable patients showed partial response. Median duration of response was 9+ months. The probability of 50% survival was 15 months for all evaluable patients. There was no case of severe toxicity and the principal toxic effects were oral mucositis and diarrhea. To date, HDFA + 5-FU is one of the most effective treatments for large bowel cancer.

ACTH 1-17 effects in the chemotherapy of advanced solid tumors

The effect of administration of a synthetic ACTH analogue (ACTH 1-17, Synchrodyn) in the chemotherapy of advanced-phase solid tumors was studied. In this preliminary report the following data are evaluated: response rate; occurrence of toxic effects; performance status of patients; several immunological parameters. The administration of Synchrodyn seems mainly to influence the lymphocyte subpopulations and the occurrence of toxic effects. A final evaluation of the role that may be played by chronotherapy in the treatment of tumors must await further studies on the clinical response and tolerance.