Long-Term Infusion in Cancer Chemotherapy with the Groshong Catheter via the Inferior Vena Cava

Aims and background

Vascular access through a vein draining into the superior vena cava is commonly used for long-term infusion of drugs inr cancer chemotherapy; prolonged cannulation of the inferior vena cava is generally considered as having an excessively high complication rate.

Methods

Prolonged cisplatin infusion via the inferior vena cava by means of a Groshong catheter was evaluated in 20 consecutive patients with thoracic malignancies showing evidence of superior vena cava infiltration or obstruction.

Results

We achieved 1,291 catheter days for our survey with a mean duration of vascular access of 64.5 days per patient and a mean duration of infusion time of 40 days. There were 2 complications, a catheter obstruction after a 7-day rest period and an ileo-femoral thrombosis 6 days after catheter placement.

Conclusions

Our experience compared favourably with the results obtained by long-term central venous access via the supraumbilical route, and demonstrated the reliability and safety of this approach in cases where the superior vena cava cannulation is technically difficult or impossible.

The Growth Rate in the Interpretation of the Natural History of Lung Cancer

The relationship between growth rate, expressed as doubling time (DT), of 110 lung cancers from randomly collected patients and patient age, sex, histological type, symptoms, smoking habits, size and lymph node involvement was studied. Median DT values of epidermoid carcinomas and adenocarcinomas were superimposable (98 and 99 days, respectively), but 15 % of adenocarcinomas had a DT of more than one year. Significant correlations were found with sex (slower growth rate in females) and symptoms (faster growth in symptomatic patients), but only for adenocarcinomas. The number of cigarettes smoked did not seem to affect the growth rate of lung cancers. There was no correlation between growth rate and tumor size or lymph node involvement.

Impact on Survival of the Extent of Resection in Unrelapsed Lung Cancer

Five-year survival of resected stage la non-oat cell lung cancer was evaluated in 69 consecutive patients without recurrence. The impact of the extent of resection on perioperative and long-term mortality was studied after an evaluation of confounding factors, such as age and associated cardiopulmonary diseases, which further stratified our series. Our patients were subdivided into 2 groups: the first included lobectomies and was further subdivided into 2 subsets according to whether the operation had caused the resection of less than 4 (30 cases) or more than 3 segments (18 cases). The second one included pneumonectomies (21 cases). Thirty-two patients were 60 years or older; pulmonary and/or cardiovascular diseases were assessed in 38 patients. There were 6 perioperative deaths, 3 among major lobectomies (more than 3 segments resected) and 3 among pneumonectomies. Survival rate of lobectomies was 75% (86% for minor, 55% for major lobectomies), and 57% for pneumonectomies. Major lobectomies included the highest percentage of elderly patients with cardiopulmonary diseases who had significantly poorer survival probabilities than young subjects without cardiopneumopathies. Lobectomy cases, after standardization by age, had a significantly higher probability of surviving than pneumonectomy cases. Standardization by cardiopulmonary disease showed a better chance for lobectomy cases, although it was not significant. Major lobectomy cases had poorer cumulative survival rate than minor lobectomy cases. Such a difference was revealed in patients 60 years or older and in those with pneumocardiopathies.

Relationship between Cambrl Expression and Tumor Progression in Small cell Lung Carcinomas

In order to study the possible relationship between antigenic phenotype and tumor progression, 63 small cell lung carcinomas (SCLC) biopsies derived from primary or metastatic tumors were tested by immunofluorescence and immunoperoxidase techniques with an anti-carcinoma monoclonal antibody designated MBr1. Primary tumors were found to be less reactive with MBr1 than the local and distant metastatic lesions (57 % versus 75 % and 89 % positivity respectively). A life table analysis on the tested cases indicated an inverse association between the expression of the marker recognized by the MBr1 MAb (CaMBr1) and overall survival (p < 0.01): patients with MBr1-positive tumors showed a shorter survival time in comparison to patients whose tumors did not express the marker. The same correlation between survival and CaMBr1 expression was found even when only the 31 cases of early stage disease patients were considered (p < 0.05). Different tumor aggressiveness or resistance to therapy of MBr1-positive tumors could be responsible for the shorter survival time of the patients.

Leiomyoma of the Esophagus

A review of the clinical records from 1947 to 1984 of the Istituto Nazionale Tumori of Milan provided 20 cases (14 males and 6 females) of esophageal leiomyoma. Eighteen of the tumors were in the thoracic esophagus and 2 were at the cardiac level. The most frequent symptoms were dysphagia, slight epigastralgia and odynophagia. Differential diagnosis should be made with mediastinic neoplasms and esophageal cancer. Barium swallow and esophagoscopy are the most sensitive procedures for a correct preoperative diagnosis. Surgery is mandatory because of the tendency to a continuous endoluminal growth (in 97% of the cases) and a possible malignant transformation. However, surgery is conservative: extramucosal enucleation of the leiomyoma is the procedure of choice. The long-term results are excellent, and morbidity is acceptable.

Modality of Lung Cancer Treatment in an Unselected Population

The modality of lung cancer treatment was retrospectively evaluated in an unselected population. All the lung cancer cases diagnosed among the residents in a Local Sanitary Unit of Lombardy during four years (1974–1979), were identified. The clinical records of the 235 collected patients were reviewed and on this basis the anatomical extent of disease was retrospectively classified in stages according to the TNM of UICC (1978). The relative frequency of clinical stages resulted 29 % for stage I, 17 % II, 20 % III and 32 % IV. Only 57 % of all the subjects had been treated; 11 % by resection, 22 % by radiotherapy and 24 % by chemotherapy. For the stages I and II the operability rates were 35 % and 26 % respectively, while the resectability rates were 29 % and 17 %. An objective reason of exclusion from surgery was found in no more than a quarter of stage I and II lung cancers, while the remaining (40 %) had probably been excluded from exploration owing to a subjective prognostic evaluation. If compared with similar reports from other countries, these data show a striking defect in the choice of curative treatment for a high proportion of the examined cases.

Surgical Resection in the Treatment of Stages I-II of Small Cell Lung Carcinoma (SCLC)

From 1981 to 1986, 17 patients with resected small cell lung carcinoma (SCLC) staged as I or II according to the new TNM classification were recruited for a prospective study to evaluate the effctiveness of surgery and postoperative chemotherapy (plus locoregional radiotherapy only when a nonradical resection was accomplished) in the treatment of early stages of the disease. Six patients received full protocol chemotherapy (6 courses) and 8 a mean of 79.1% of the planned courses. Three patients received non adjuvant treatment. Locoregional radiotherapy for residual disease was administered in 2 cases. One patient died for myelosuppression due to chemotherapy and 10 for recurrences of cancer, all within the 20th postoperative month. Metastases accounted 80% of overall recurrences. Six patients were alive and tumor-free at 18, 22, 39, 44, 47 and 51 months from resection. Actuarial observed 3-year survival was 32%.

Post-Thoracotomy Diagnostic and Staging Conversion Rates of Clinically Staged I Lung Cancer

The accuracy of stage I lung cancer assessment achieved by traditional clinico-diagnostic staging was retrospectively evaluated in 164 consecutive patients who underwent thoracotomy. The diagnostic conversion rate was 6.7 % (1 carcinoid and 10 innocent pulmonary lesions) and occurred only in the subset of patients lacking preoperative pathologic confirmation (15 %). The conversion rate to unresectable tumor extent was 8 % (11/153), and local spread was the main cause of unresectability (5.5 %). The staging conversion rate was 29 % (43/153): the conversion rate for nodal evaluation was double that of primary tumor evaluation (24 % versus 12 %), but conversion to anatomically unresectable nodal diffusion occurred in only one patient (0.6 %). The ability of the surgeon to convert the wrong diagnosis was scanty without extemporary biopsy, and 7 patients with innocent lesions underwent standard resection for primary cancer. Surgical staging was as precise as pathological staging in primary tumor evaluation, but was faulty in nodal evaluation (15 % error in sN0 and sN1-2 assessment). It is concluded that following stage I lung cancer assessment by traditional means, supplementary examinations are requested for a better sensitivity of pathological confirmation and a better refinement of local spread. Better nodal evaluation has less value until a biologic limit to surgery for anatomically resectable nodal diffusion is universally accepted.

Incident Lung Cancer Survival. Long-Term Follow-Up of a Population-Based Study in Italy

The long-term survival of an incident lung cancer population was evaluated in relation to clinical stage, treatment modalities and other prognostic factors. The survey was carried out among the residents in the Local Sanitary Unit of Saronno, a highly industrialized area of northern Italy, where all the lung cancer cases diagnosed during the years 1976-79 had been identified and clinically studied. The overall survival of the 222 cases included in the analysis was 32% at 1 year, 10% at 3 years and 5% at 5 years; median survival was 7 months. A significantly better prognosis was associated with surgical resection (32% at 5 years; median, 42 mo), clinical stage I (16% at 5 years; median, 15 mo), and squamous cell carcinoma (13% at 5 years; median, 11 mo). Other factors such as age, sex, social class or cancer symptoms did not affect survival when treatment was taken into account. Our data show that surgical resection is the major determinant of survival, and suggest that suboptimal access to curative treatment, particularly in patients aged 60 to 75 with limited disease, might have compromised the overall survival.

Results of Conservative Surgery for Stage I Lung Cancer

This paper reports our results with sublobar resections for stage I non small cell lung cancer. Sixty-one cases of wedge or segmental resection were compared with 517 standard resections (411 lobectomies and 106 pneumonectomies), performed during the years 1971–88. Operative mortality was 0% in the limited resection group and 4 % (19/517) in the standard resection group; cancer recurrence was detected in 36 % of both groups; actuarial survival at 5 years was 55% versus 48% overall. In 28 patients with pre-existing cardiac or pulmonary co-morbidity, limited resection yielded a similar 5-year survival than standard resection (53 % vs 49 %) with no perioperative deaths (0 vs 6 %). Our data support the experience of other authors on conservative management of stage I lung cancer. Particularly in patients with concomitant cardiopulmonary disease, previous cancer or small peripheral tumors, limited resection combined with adequate nodal staging may be as effective as standard lobar resection with respect to long term survival.

Late Results after Sleeve or Wedge Lobectomies for Non-Small-Cell Lung Carcinoma

From January 1971 to June 1983, 35 lobectomies with bronchoplastic procedures for invasive non-small-cell lung carcinoma were performed. Sleeve lobectomy was carried out in 21 cases, wedge lobectomy in 11, and upper sleeve bilobectomy in 3. There were 23 stage I, 10 stage II, and 2 stage IIIa tumors. Completion pneumonectomy was required in 1 case for anastomotic fistula and in 2 for atelectasis of residual lung. One of these patients died later due to empyema. The 5-year probability of death with recurrence was 31.98%. The 5-year disease-free survival was 58.57%. Metastatic relapse was observed in 8 cases and locoregional recurrence in 5. A new primary lung tumor occurred in 2 patients.

Preoperative Irradiation and Surgery for Esophageal Cancer: Causes of Failure

Twenty-seven patients with squamous esophageal cancer underwent small-volume, low-dose, concentrated radiotherapy followed by esophageal resection whenever possible (esophagectomy for tumors of the thoracic esophagus and esophagogastrectomy for tumors of the lower esophagus). Curative resectability was 70% (19/27) with 4 operative deaths (21%). Recurrence rate was 66% after a mean period of 16 months, and the failure pathway was nodal in 53% of the cases. Historical comparison of the data suggests that preoperative irradiation increases the curative resectability rate without changing the early recurrence rate or failure pathway. Tumors with deeper invasion of the esophageal wall, which benefit by preoperative irradiation, are probably related to greater nodal diffusion, which is partly outside of the volume that may be resected or irradiated.

Current Results of Esophageal Cancer Surgery. Time Trends in Operative Mortality and Long Term Survival

This paper represents a historical analysis of the results achieved by esophageal cancer surgery over the last three decades, as they appear in the literature of the years 1954–1985, and in our own experience between 1965 and 1985, with the aim of assessing the evolution of operative mortality and long-term survival. In a review of 4930 resections reported in western literature, mean values of perioperative mortality went down from 30 % to 9 %, while the five-year survival increased from 8 % to 19 %. Similar changes were evident in Japanese and Chinese literature where the survival rose from 9 % to 23 % in unscreened populations and up to 90 % in early cancers. In our experience, dividing the series in two decades (1965–74 and 1975–85), the overall perioperative mortality changed from 28 % to 13 %. The actuarial survival for the two periods was 8 % vs 18 % at 5 years, with a median survival of 9 and 18 months. A greater difference was evident for NO patients where the survival rose from 15 % to 35 % at 5 years, with a median survival of 15 vs 38 months.

Five-Year Recurrence Probabilities in 330 Patients Curatively Resected for Stage Ia Bronchogenic Carcinoma

Three hundred and thirty consecutive cases of resected Stage Ia (TNM UICC classification) lung carcinomas were retrospectively reviewed with the aim of evaluating actuarial probabilities of recurrence within the 5th year from operation, according to the extent of resection, the cell type, and the T number. The probabilities of recurrence according to the pattern of failure were also assessed. Five-year overall probability of recurrence was 46.3 %. Pneumonectomies showed a lower rate of relapse (37.4 %) than lobectomies (49.2 %), even though non significant. However, patients submitted to a lobectomy had a higher rate of 5-year survivors. Cell type had no significant impact on the probability of recurrence. 35.5 % of patients with T1 carcinomas had evidence of relapse compared with 51.1 % of patients with T2 tumors. This datum is explained by the presence in T1 group of a high share of squamous cell cases. Patients with T1 squamous cell carcinomas had, in fact, the best prognosis (26.5 % recurred) among the subgroups obtained by stratification of T number and cell type together; loco-regional failure as exclusive modality of relapse had a 5-year rate of 19.7 % and metastatic failure of 30.0 %. Adenocarcinomas had a significantly higher impact on the occurrence of brain metastases.

Lung Resection as Salvage Treatment for Metastatic Osteosarcoma

Resection of pulmonary metastases has achieved a central role in the overall management of osteosarcoma, since a number of studies have demonstrated that salvage surgery is able to cure 20 to 40% of all relapsing patients. This paper presents the results of surgical management of 27 consecutive cases of pulmonary metastases from osteosarcoma, who underwent complete resection at the Istituto Nazionale Tumori of Milan between 1975 and 1986. In the present series, overall actuarial survival at 3 years from the first thoracotomy was 47%, with a median survival of 28 months and no operative mortality. Better results were observed in patients with single lesions (68% survival) or when the interval to lung metastases exceeded 12 months (60% survival). These data support the concept of pulmonary metastasectomy as effective salvage therapy for metastatic osteosarcomas whose distant spread is confined in the lungs.

Angiofollicular Lymph Node Hyperplasia

A case of angiofollicular hyperplasia of a lymph node on the right pulmonary hilus is described. The mass 5 cm large was strictly adherent to the pulmonary arteria; its cure required pneumonectomy.

Pretreatment HIV-1 drug resistance in Argentina: results from a surveillance study performed according to WHO-proposed new methodology in 2014-15

BACKGROUND

In Argentina, current national guidelines recommend starting with NNRTI-based regimens. Recently, there have been some local reports regarding concerning levels of NNRTI-transmitted resistance, but surveillance has never been carried out at a national level.

OBJECTIVES

To determine the prevalence of HIV drug resistance in people starting ART in Argentina using a WHO-proposed methodology.

METHODS

This was a cross-sectional, nationally representative study. Twenty-five antiretroviral-dispensing sites throughout the country were randomly chosen to enrol at least 330 persons starting ART, to generate a point prevalence estimate of resistance-associated mutations (RAMs) with a 5% CI (for the total population and for those without antiretroviral exposure). All consecutive patients older than 18 years starting or restarting ART in the chosen clinics were eligible. Samples were processed with Trugene and analysed using the Stanford algorithm.

RESULTS

Between August 2014 and March 2015, we obtained 330 samples from people starting ART. The mean ± SD age was 35 ± 11 years, 63.4% were male, 16.6% had prior antiretroviral exposure and the median (IQR) CD4 count was 275 cells/mm³ (106-461). The prevalence of RAMs found was 14% (±4%) for the whole population (3% NRTI-RAMs; 11% NNRTI-RAMs and 2% PI-RAMs) and 13% (±4%) for those without prior antiretroviral exposure (3%, 10% and 2%, respectively). The most common mutation was K103N.

CONCLUSIONS

This surveillance study showed concerning levels of HIV drug resistance in Argentina, especially to NNRTIs. Due to this finding, Argentina's Ministry of Health guidelines will change, recommending performing a resistance test for everyone before starting ART. If this is taken up properly, it also might function as a continuing surveillance tool.

Esophageal Carcinoma

Twelve minimal lesions were found over a period of 18 months at the Istituto Nazionale Tumori of Milan at the end of the radiologic, endoscopic and histologic procedures. Eleven lesions were radiologically detected, and a radiologic diagnosis of malignancy was perspectively made in 10 of the identified lesions. The radiologic aspects of minimal lesions are described. Double contrast study of the esophagus allows excellent mucosal detail and good reproduction of lesions. Simplicity and minimal discomfort for the patient justify it as a first diagnostic step for detection of neoplastic pathology.

Comparison of glomerular filtration rate estimates vs. 24-h creatinine clearance in HIV-positive patients

BACKGROUND

Guidelines for kidney function monitoring and antiretroviral drug dosing are available and respectively refer to glomerular filtration rate and creatinine clearance (CrCl).

OBJECTIVE

The aim of the study was to compare kidney function estimates vs. measured 24-h CrCl in HIV-infected subjects.

METHODS

A cross-sectional design was used, with comparison of Cockcroft-Gault (CG), original and simplified modification of diet in renal disease (MDRD) equations vs. measured 24-h CrCl. Subjects were HIV-infected, 18-70 years old, without pre-existing kidney disease.

RESULTS

Results are presented as mean (+/-standard deviation), unless otherwise stated. The study population consisted of 90 patients, of whom 71% were male, with a mean age of 45 years (+/-6.5 years). At the time of evaluation, the mean body mass index was 23 (+/-3.3); mean serum creatinine was 0.91 mg/dL (+/-0.2 mg/dL); and mean blood urea nitrogen (BUN) was 34.7 mg/dL (+/-10.6 mg/dL). Differences between paired methods were all significant (P<0.00001), except between CG and simplified MDRD (P=0.21; Pearson r=0.81). In univariate analysis, male gender, CD4 nadir, hepatitis B virus coinfection, BUN and current CD4 cell count showed a significant positive correlation (P<0.2) with the difference between measured 24-h CrCl and either CG or simplified MDRD estimates. In multivariate analysis, only BUN showed a significant positive correlation (P<0.05).

CONCLUSIONS

Estimates were lower than the measurements of 24-h CrCl. Original MDRD estimates were lower than those with other equations. CG and simplified MDRD estimates showed a satisfactory correlation.

Differential diagnosis and management of focal ground-glass opacities

Focal pulmonary ground-glass opacities (GGOs) can be associated with bronchioloalveolar carcinoma. The present retrospective study aimed to test the validity of a multistep approach to discriminate malignant from benign localised (focal) GGOs, identifies useful diagnostic features on computed tomography (CT), and suggests appropriate management guidelines. A stepwise approach, including oral antibiotics, follow-up high-resolution CT (HRCT) 40-60 days later and CT-guided core biopsy, was used. All cases with localised GGOs detected since 2001 were reviewed. CT features were described according to a structured scheme. In total, 40 patients were evaluated. Of these, 11 patients were diagnosed with benign GGOs, 19 patients had lung cancer and 10 were undetermined. Nonpolygonal shape, apparent radial growth and clear-cut margins were associated with a malignant histology. The specificity of CT findings was low. Diagnostic accuracy increased after oral antibiotics, follow-up HRCT and percutaneous core biopsy. Overall, 18 patients underwent surgery for lung cancer. In conclusion, malignant ground-glass opacities have a fairly typical appearance, but some benign lesions closely mimic their malignant counterparts. The stepwise approach adopted in the present study increased the diagnostic specificity and reduced time to definitive diagnosis. Segmentectomy might be the ideal resection volume for such tumours.

Effectiveness of stereotactic body radiotherapy in the treatment of inoperable early-stage lung cancer

BACKGROUND

Non-small cell lung cancer (NSCLC) is the leading cause of cancer death worldwide. Stereotactic body irradiation offers a non-invasive treatment modality for patients with early stage NSCLC who are not amenable to surgery or other invasive approaches because of their poor medical condition.

PATIENTS AND METHODS

Forty-three inoperable patients with NSCLC were treated with SBRT at our institution. A mean total dose of 30.5 Gy in 1-4 fractions was applied. The median follow-up duration was 14 months (range 6-36 months).

RESULTS

The actuarial survival at two years was 53%: two patients died from cancer progression whereas a further 8 patients died from comorbidities. Acute toxicity was practically absent, with 7 (16.3%) patients suffering from grade 1 symptoms and two from (4.6%) grade II effects. At the time of this report, only 1 patient had grade II and 6 patients (13.9%) grade I chronic symptoms.

CONCLUSION

Our results compare favourably with recently published studies and confirm that stereotactic radiotherapy has the potential to produce high local control rates with a low risk of lung toxicity in patients not amenable to curative resection. The low grade of side-effects is encouraging for shortening the treatment using a greater dose per fraction.

[Chest wall and vertebral en-bloc resection for sarcoma: ten-year experience]

AIM

We reviewed our ten-year experience with surgical en-bloc chest wall and vertebral resection for sarcoma invading the spine, and verified five-year survival and feasibility of this aggressive surgery.

METHODS

From 1994 to 1999, 13 patients underwent surgical en-bloc resection for primary sarcoma of the chest wall involving the spine. Concurrent pulmonary resection was performed in 12 cases. A single hemi-vertebrectomy was performed in 2 patients, a triple hemi-vertebrectomy in 2, a complete vertebrectomy in 4, a triple complete vertebrectomy in 5.

RESULTS

Significative morbidity occurred in 1 patient who had lower limbs paralysis (9%). Perioperative mortality occurred in 2 patients (15.4%): 1 operative death for bleeding and 1 patients for a adult respiratory distress syndrome (ARDS). The overall five-year survival was 30.8%, excluding the 2 perioperative deaths the five-year survival resulted 36.4%.

CONCLUSIONS

In spite of the limited number of patients, the morbidity and mortality outcome and the five-year survival leads us to think that surgery is the main therapy for primary chest wall sarcomas involving the spine. En-bloc chest wall and vertebral resection is a safe and effective treatment.

K-ras and p16INK4Aalterations in sputum of NSCLC patients and in heavy asymptomatic chronic smokers

NSCLC rates among the most frequent and lethal neoplasm world-wide and a significant decrease in morbidity and mortality relies only upon effective early diagnostic strategies. We investigated K-ras mutations and p16(INK4A) hypermethylation in tumor tissue and sputum of 50 patients with NSCLC and correlated them with sputum cytology and with tumor staging, grading and location, to ascertain, in sputum, their potential diagnostic impact. The same genetic/epigenetic abnormalities and cytological features were also evaluated in sputum from 100 chronic heavy smokers. Genetic analysis identified molecular abnormalities in 64% tumors (14/50 K-ras mutations and 24/50 p16(INK4A) hypermethylation) and in 48% sputum (11/50 K-ras mutations and 16/50 p16(INK4A) hypermethylation). In tumors K-ras mutations and p16(INK4A) hypermethylation were mostly mutually exclusive, being found in the same patients in 3 cases only. Genetic abnormalities in sputum were detected only in molecular abnormal tumors. Molecular changes in sputum had rates of detection similar to cytology (42%) but the cyto-molecular combination increased the diagnostic yield up to 60%. Interestingly, the rate of detection of genetic changes in sputum of tumors at early stage (T1) was not significantly different from that of tumors at more advanced stage (T2-T4). In fact K-ras point mutations were frequently recognised in tumors at early stage while p16(INK4A) inactivation prevailed in tumors at advanced stage ( P=0.0063). As expected, diagnostic cytological findings were more frequently found in tumors at advanced stage (P=0.004). No correlation was found between tumor grading and location (central versus peripheral) and molecular changes. p16(INK4A) hypermethylation, but not K-ras mutations, was documented in sporadic cases of asymptomatic heavy smokers (4%) where it was uncoupled from cytological abnormalities. In conclusion the cyto-molecular diagnostic strategy adopted in this study was able to detect the majority of tumors but in order to be proposed as effective and early diagnostic tool, this molecular panel needs to be tested in prospective studies with adequate follow-up.

Activity of a specific inhibitor, gefitinib (Iressa™, ZD1839), of epidermal growth factor receptor in refractory non-small-cell lung cancer

BACKGROUND

Gefitinib (Iressa(TM), ZD1839) is an orally active, selective epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor. Phase I studies showed that it is well tolerated, with evidence of tumor regression in patients with advanced non-small-cell lung cancer (NSCLC). Therefore, we aimed to assess the antitumor activity and tolerability of gefitinib in a series of patients with previously treated, advanced NSCLC, as a part of a compassionate use program.

PATIENTS AND METHODS

To be eligible, all patients were required to have histologically or cytologically proven advanced or metastatic NSCLC, prior chemotherapy with at least one cisplatin-containing chemotherapy regimen or contraindication to cytotoxic drugs, Eastern Cooperative Oncology Group performance status < or =2, and adequate hematological, renal and hepatic parameters. All patients provided signed informed consent. Patient re-evaluation was performed every 4-6 weeks.

RESULTS

Seventy-three consecutive patients were enrolled. Response rate, including complete and partial response, was 9.6%; an additional 43.8% of patients achieved stable disease, for an overall disease control of 53.4%. EGFR1 status was evaluated by immunocytochemistry in 25 patients. According to EGFR1 immunoreactivity all responses were observed with medium/strong imunoreactivity while three out of four responses were observed in high expressive patients. Median survival for all patients was 4 months while it reached 6 months for patients with disease control. The 1-year survival rate was 13.1% for the entire series and 23.2% for patients with disease control. Non-hematological toxicity was generally mild.

CONCLUSION

Gefitinib has promising activity with a good toxicity profile in patients with progressive NSCLC who have received one or two prior chemotherapy regimens. A possible relationship within response and EGFR1 expression is suggested.

Three-week versus four-week schedule of cisplatin and gemcitabine: results of a randomized phase II study

BACKGROUND

The cisplatin and gemcitabine (GC) regimen is usually administered as a 4- or 3-week schedule; however, the best schedule to use is still unclear. We therefore started a randomized phase II trial to compare toxicity and dose intensity (DI) between these two GC schedules.

PATIENTS AND METHODS

Ninety-six patients with non-small-cell lung cancer (NSCLC) and an additional 11 patients with an advanced epithelial neoplasm [bladder (n = 5), head and neck (n = 3), cervix (n = 1), esophageal (n = 1) or unknown primary carcinoma (n = 1)] were randomized to receive cisplatin 70 mg/m(2) intravenously on day 2 plus either gemcitabine 1000 mg/m(2) on days 1, 8 and 15 of a 28-day cycle or gemcitabine 1000 mg/m(2) on days 1 and 8 of a 21-day cycle. Planned DI (PDI) for the 4-week schedule was 750 mg/m(2)/week for gemcitabine and 17.5 mg/m(2)/week for cisplatin; for the 3-week regimen PDI was 666 mg/m(2)/week and 23 mg/m(2)/week for gemcitabine and cisplatin, respectively.

RESULTS

From July 1998 to March 2000, 107 patients were randomized. Grade 3/4 neutropenia was observed in 27.8% of patients in the 3-week versus 22.5% in the 4-week arm (P = 0.69), while grade 3/4 thrombocytopenia was higher in the 4-week arm (29.5% versus 5.5% of patients; P = 0.14). A total of 398 cycles of therapy were delivered. Overall, 51% of cycles were modified in dose, timing or both in the 4-week arm, and 19% in the 3-week arm. The 21-day schedule of GC leads to a similar received DI of gemcitabine and higher cisplatin DI. Both regimens had activity in NSCLC, with a response rate of 39% (38% for the 4-week arm, and 42% for the 3-week arm).

CONCLUSIONS

The 3-week schedule has similar DI to the 4-week schedule. However the 3-week regimen has a better compliance profile and a comparable response rate in NSCLC, supporting the use of such a schedule.

Thoracoscopic resection of an esophageal stromal tumor through the left pleural cavity

We describe the technique for endoscopic removal of a stromal tumor of the lower third of the esophagus through the left thoracoscopic approach. The tumor resembled a leiomyoma and was classified as a borderline, potentially malignant lesion after thoracoscopic removal. The technique and clinical implications in such cases are discussed on the basis of current knowledge.

Bcl-2 protein and prognosis in patients with potentially curable non-small-cell lung cancer

The bcl-2 proto-oncogene functions as a cell death suppressor, and its expression prolongs cell survival by blocking apoptosis. Data available on the clinical relevance of bcl-2 protein expression in patients with non-small-cell lung cancer (NSCLC) are controversial. We analysed the role of bcl-2 protein expression on 6-year relapse-free survival in 229 patients with stage I-IIIa NSCLC (101 squamous cell carcinomas and 128 adenocarcinomas) subjected to surgery, with curative intent. Immunohistochemical analysis was performed on archival material by using a monoclonal antibody anti-bcl-2 (clone 124). Bcl-2 protein expression, which was detected in 22% of the cases, was significantly related to stage, histology and grading, and was an indicator of clinical outcome. The probability of relapse-free survival at 6 years was longer for patients with bcl-2-positive tumours (74%) than for those with bcl-2-negative tumours (57%) (P=0.02). This finding was mainly evident for the subgroups of patients with stage IIIa tumours (P=0.05), squamous cell carcinoma (P=0.03) or moderately/poorly differentiated tumours (P=0.02). However, multivariate analysis by Weibull's regression model indicated that bcl-2 protein expression was not an independent prognostic risk factor in patients with curable NSCLC when the information provided by stage was available.

Sternal resection for primary or secondary tumors

METHODS

From January 1980 to December 1993, 52 patients underwent surgical-resection for tumors involving the sternum. The series included 20 primary malignant tumors, 4 desmoid tumors, 2 malignant tumors infiltrating the sternum from adjacent organs, 19 local recurrences or metastases of breast tumors, and 7 metastases of other tumors. Total sternectomy was performed in 5 patients, subtotal sternal resection in 19, and partial resection (less than 50% of the sternum) in 28. Concurrent en bloc resection included anterior ribs in 37 patients, clavicle in 11, lung in 12 patients, pericardium in 7, and diaphragm in 2. The chest was reconstructed with prosthetic material and a myocutaneous flap in 26 patients (50%), prosthetic material only in 12 patients (23%), a myocutaneous flap in 5 patients (10%), and other techniques in the remaining patients. In 47 patients (90%) the resection was radical, and in the remaining 5 patients it was palliative.

RESULTS

No perioperative deaths occurred. After a median follow-up of 39 months, the overall 3-year survival was 58% and the 5-year survival 46%, with a median survival of 50 months. In 24 patients with primary tumor the 5-year survival after radical resection was 63%, and in 23 patients with secondary invasion (direct extension or metastasis) the 5-year survival was 38% (median 35 months). In recurrent breast cancer the 5-year survival was 48% in patients with direct extension to the chest wall and 60% in patients with distant bone metastasis.

CONCLUSIONS

Our experience demonstrates that sternal resection is a safe and effective treatment, which may improve the patient's quality of life and achieve a long-term survival not only in primary tumors but also in selected secondary malignant tumors of the sternum.

P53 expression, DNA ploidy and S-phase cell fraction in operable locally advanced non-small-cell lung cancer

The identification of biomarkers to complement pathological stage for a more accurate prognosis and help clinicians decide on treatment is still an open problem for patients with lung cancer. Expression of P53 protein was detected by an immunohistochemical approach using the monoclonal antibody PAb1801 on paraffin-embedded sections of tumours obtained surgically from 102 stage II - IIIa patients with non-small-cell lung cancer (52 squamous cell carcinomas, 50 adenocarcinomas). [3H]Thymidine labelling index, an indicator of the S-phase cell fraction, was evaluated on histological sections of [3H]thymidine-labelled tumour samples. DNA ploidy was defined by flow cytometric analysis on frozen tumour tissue. The biomarkers, histology and pathological stage were analysed in relation to relapse-free survival in univariate and multivariate analyses. Stage and interaction between [3H]thymidine labelling index and histology provided significant prognostic information for the overall series. [3H]thymidine labelling index was an independent prognostic indicator of 3 year relapse-free survival in patients with adenocarcinoma. The results indicate the importance of cell proliferation to complement prognostic information provided by pathological stage in patients with stage II-IIIa adenocarcinomas.

Conservative management of esophageal leaks by transluminal endoscopic drainage of the mediastinum or pleural space

BACKGROUND

The management of postoperative leaks into the mediastinum or pleural cavities after esophageal surgery yields unsatisfactory results. A recently described method, drainage of the mediastinum or pleural cavity through suture line defects, has been used in our department with eight patients.

METHODS

A suction tube was advanced over an endoscopically placed guide wire into the abscess from inside the esophagus, and gentle aspiration was used to remove saliva and secretions. Intravenous antibiotics and total parenteral nutrition were also given.

RESULTS

The sepsis was rapidly controlled, and the abscess cavity progressively collapsed in all cases. Seven patients recovered and were discharged 34 to 61 days after operation; one died of concomitant complications.

CONCLUSIONS

This method seems promising for the management of intrathoracic esophageal leaks.

Ambulatory low-toxicity chemotherapy in non-small-cell lung carcinoma by continuous 28-day infusion of alternating cisplatin and 5-fluorouracil

BACKGROUND

One regimen consisting of a continuous infusion of cisplatin and fluorouracil was designed to be minimally toxic, and suitable for application with radiotherapy in non-small-cell lung carcinoma (NSCLC).

PATIENTS AND METHODS

Forty-four NSCLC patients received daily 8 mg/m2 of cisplatin on days 1-2, 8-9, 15-16, 22-23, and 300 mg/m2 of fluorouracil on days 3-7, 10-14, 17-21, 24-28 (35-day courses).

RESULTS

Two patients experienced grade 3-4 toxicities. Eleven achieved objective responses. The median progression-free and observed survival was 22 and 39.5 weeks.

CONCLUSIONS

The schedule management was fully ambulatory. Toxicity was negligible. The activity was moderate, but the combination with radiotherapy is advisable due to the radioenhancing properties of both of the drugs.

A summary of the Milan experience with multimodality therapies in patients with small cell lung cancer: attempts to improve long-term outcome

From February 1985 to June 1993, 173 consecutive, previously untreated patients with small cell lung cancer received individualized treatment tailored to disease extent. Almost all patients (14 of 16) with stage I and II disease and 30 patients with operable stage III disease were submitted to surgery preceded or followed by chemotherapy. Chest irradiation and prophylactic brain radiotherapy (in complete responders) were administered at the end of treatment in 42 of 44 cases. Patients with inoperable limited disease received chemotherapy followed by radiotherapy in 67 of 71 cases, while chemotherapy alone or followed by radiotherapy in sites of either initially bulky or residual disease was administered to 58 patients with extensive disease. The overall response rate was 77% (complete response, 45%; partial response, 32%). Complete responses were documented more frequently in limited disease than in extensive disease (57% v 22%; P < .001). The 2- and 5-year freedom from progression rates (24% and 16%, respectively), as well as overall survival rates (31% and 16%, respectively) were significantly affected by disease extent. No patient with extensive disease was progression free and alive at 2 years, while more than half of stage I and II patients were disease free and alive at 5 years. This retrospective analysis performed on a large number of consecutive, nonrandomized patients suggests that, at least in patients with limited disease, it is possible to achieve favorable long-term results using treatment tailored to disease extent. Nonetheless, the disappointing results commonly achieved in the treatment of small cell lung cancer strongly support the need for either prospective, randomized studies to confirm recently reported improved results or new pilot studies with investigation of entirely innovative approaches.

Determination of platinum in plasma of patients affected by inoperable lung carcinoma treated with radiotherapy and concurrent low-dose continuous infusion of cis-dichlorodiammine platinum(II)

Platinum microquantities were determined in plasma of patients affected by lung carcinoma during treatment with radiotherapy (RT) and concurrent low-dose continuous infusion of cis-dichlorodiammineplatinum(II) (CDDP). RT was given at 50 Gy in continuous course; CDDP was continuously infused at 4 mg/m2 daily for 100 h/week for 5 weeks, and the infusions were separated by 68 h of rest. The percentage of free drug versus total drug in plasma was about 3%. It did not vary with therapy duration and was not significantly different from that found in 5-day continuous infusions at much higher daily doses. Nevertheless, maximal values of free Pt in plasma were very low and agreed with the low level of CDDP toxicity encountered on the present administration schedule.

Cyfra 21-1 - a new tumor-marker for lung-cancer

Among 20 known cytokeratins, cytokeratin fragment 19 is a 40 kD acidic molecule whose distibution is restricted to simple or pseudo-stratified epitelia, such as the epithelial layer of the bronchial tree. An immunoradiometric assay, CYFRA 21-1, was used to detect a fragment of cytokeratin 19 in the serum of 90 subjects and compared with serum levels of CEA, NSE and TPA. Sixty-seven consecutive patients with lung cancer and 23 healthy subjects were tested. Cut-off values for tumor markers were considered as the 95% of specificity versus controls. There were 32 adenocarcinomas, 29 squamous carcinomas and 6 other tumors. Increased serum levels of CYFRA 21-1 were found in lung cancer patients compared to controls [1.6 (0.2-3.2) versus 0.5 (0.2-1.8): p<0.001]. In our study TPA was more sensitive than CYFRA 21-1: 49% versus 40%; when we combined both markers the sensitivity increased to 63%. Significant difference in values were found before and after surgery in serum levels of 34 operated patients: p<0.01. We found higher levels of soluble cytokeratin 19 in lung cancer patients and in the adenocarcinoma subgroup. This study does not support the exclusive use of soluble cytokeratin 19 as a specific marker of lung cancer and not only in squamous carcinoma subgroup. This suggested that diagnostic and prognostic sensitivity increase when CYFRA 21-1 and TPA or other markers are combined.

Surgery after radiochemotherapy for stage III lung cancer: postoperative complications and late results

Fifty-seven stage III lung cancer patients underwent radiochemotherapy and subsequent surgery. Forty radical (R-), six non-radical, and eleven exploratory operations were performed. Pneumonia (five cases), pulmonary insufficiency (one case), bronchial fistula (one case) were the major non-fatal complications. Four deaths due to adult respiratory distress syndrome (ARDS) or pulmonary embolism occurred. Sixty percent of the 10 patients who had no viable tumor at operation survived 3 years, as well as 41% of those who achieved a complete remission by resection and 11% of those with residual disease (R+) after operation. However, the 1- and 2-year survival rates were similar. The main pattern of failure in R- and R+ patients was extra- and intra-RT-field progression, respectively. A slightly higher rate of postoperative complications, with respect to current practice, was observed. However, data lead to argument on the improvement of locoregional control and long-term survival following radical surgery.

Safety of absorbable suture for sternal closure after pulmonary or mediastinal resection

The reliability of polyglyconate monofilament (Maxon) suture for sternal closure was tested on 216 consecutive sternotomies, performed on 208 patients in our department from January 1986 to December 1990. The reason of sternotomy was primary lung cancer in 34 cases (16%), lung metastases in 127 (59%), and disorders of the thymus in 55 (25%). Mean age was 38 years (range 3 to 78 years); multiple lung resections were performed in 102 patients (average 7 lesions, range 2 to 30); maximum extent of the operation was pneumonectomy in 2 cases, lobectomy in 53, segmentectomy in 27, and wedge resection in 74. Prior chemotherapy had been administered in 75 cases (35%). A second sternotomy was performed in 8 cases. No cases of sternal dehiscence, sternal infection, or empyema were observed, after a median follow-up of 27 months. Overall perioperative mortality was 0.9% (2/216). Our series demonstrates the safety of polyglyconate monofilament (Maxon) suture for sternal closure. Absorbable sutures appear to be a safe alternative to steel wire closure in patients undergoing extended pulmonary or mediastinal resection.

Preoperative concomitant cisplatin/VP16 and radiotherapy in stage III non-small cell lung cancer

PURPOSE

To evaluate the therapeutic effectiveness of a combined chemoradiotherapy program, followed by surgery in selected cases, in Stage III non-small cell lung cancer.

METHODS AND MATERIALS

Between August 1988 and February 1990, 43 patients Staged IIIa-b (UICC 1987, 58% IIIb) have been treated with concomitant chemotherapy (cisplatin 15 mg/m2 and VP16 75 mg/m2, 5 days a week on week 1 and 5) and radiotherapy (40 Gy split course, 2 Gy/day on week 1, 2, 5, and 6), followed by attempted curative thoracotomy or more cycles of full dose chemotherapy with the same two drugs.

RESULTS

Planned chemoradiotherapy has been given to 91% of patients; 13/43 patients have been operated, with 12 complete resections and three (7%) pathological complete responses. Toxicity was significant, with two postoperative deaths and two fatal radiation pneumonitis. Crude progression-free survival rate is 21% at 30 months, with nine patients (21%) alive and free from progression at follow-up times ranging from 31 to 49 months. Subset survival analysis showed a possibly greater therapeutic effect for non-squamous histology as compared to squamous carcinoma.

CONCLUSION

These results are encouraging in a cohort of patients with quite advanced disease (58% Stage IIIb).