Long Term Persistent Alopecia and Suboptimal Hair Regrowth after Adjuvant Chemotherapy for Breast Cancer: Alert for an Emerging Side Effect: ALOPERS Observatory

Background: Since 2003, through the impetus given by Pr Erick Gamelin and the Regional Health Agency in Western France (Bretagne, Pays de Loire), a network called OMIT (Drugs and Emerging Therapeutics Observatory) has been created, including the Breast Cancer Forum. Anthracyclins and taxanes are the cornerstones of adjuvant chemotherapy for breast cancer. In France, since the PACS 01 publication1, FEC 100 followed by docetaxel 100 has been the standard adjuvant chemotherapy regimen in breast cancer. Long term toxicities like persistent alopecia or suboptimal hair regrowth have been observed.Methods: Over the last year, the first cases of persistent alopecia or suboptimal hair regrowth after adjuvant chemotherapy have been reported to the Breast Cancer Forum. Consequently, OMIT quickly drew up a case report form and mailed it to every oncologist in Western France to collect data.Results: From May 2008 to April 2009, 66 cases of persistent alopecia or suboptimal hair regrowth after adjuvant chemotherapy from 15 different institutions were declared to OMIT: median age: 60 years (35-78), hypothyroidia: 11, fine hair before treatment: 2. Alopecia was localized: 13, diffuse: 49, complete: 4. The time lapse between the end of chemotherapy and persisting alopecia has been more than 3 months: 5 patients, more than 6 months: 10, more than 12 months: 22, more than 24 months: 29. The chemotherapy regimens were various: schedule FEC (epirubicin 100 mg/msq), 3 courses followed by docetaxel 100 mg/msq, 3 courses: 54, docetaxel 100 mg/msq: 3, TCH (docetaxel-carboplatin-trastuzumab) or TH: 2, FEC 100: 2, epirubicin 75 mg/msq in association with docetaxel 75 mg/msq: 2. Hormonotherapy: letrozole: 13, anastrozole: 18, exemestane: 3, tamoxifene: 14, LH-RH agonist: 3. No hormonotherapy: 13. In some institutions, according to the ECOG trial2, some oncologists quickly decided to change their standard regimen from FEC 100 - docetaxel 100, to EC 100 4 courses followed by weekly paclitaxel for 12 weeks: forthcoming data on persistent alopecia, suboptimal hair regrowth or neuropathy after this ECOG adjuvant chemotherapy regimen will be presented at the symposium.Conclusion: For the first time in France, Western OMIT offers us data about persistent alopecia or suboptimal hair regrowth after adjuvant chemotherapy: it is an important side effect and must be considered by oncologists as optimal information to give to curable patients. The next step is to evaluate the real incidence of this phenomen on the population of patients treated by adjuvant chemotherapy for breast cancer: OMIT is currently working with the Federation Nationale des Centres de Lutte contre le Cancer (FNCLCC) to collect data from prospective trials such as PACS 01 (FEC versus FEC-docetaxel), PACS 04 (FEC versus epirubicin-docetaxel) and PACS 05 (FEC 6 courses versus 4 courses), to create the ALOPACS database.1- Roché H. Sequential Adjuvant Epirubicin-based Regimen and Docetaxel Chemotherapy for node-positive Breast Cancer Patients: the FNCLCC PACS 01 Trial. J Clin Oncol. 2006 dec 20; 24 (36) 5664-71.2- Sparano JA.Weekly Paclitaxel in the Adjuvant Treatment in Breast Cancer. N Engl J Med. 2008 Apr 17; 358(16): 1663-71.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3174.

Intraoperative intraperitoneal (IP) chemotherapy with cisplatin and escalated dose of epinephrine in patient with recurrent peritoneal carcinomatosis of ovarian cancer: A phase I study

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Background: IP epinephrine (E) has been shown to enhance the accumulation and antitumor activity of IP cisplatin in rats with peritoneal carcinomatosis (Duvillard et al. Int J Cancer, 1999). E induces a vasoconstriction of peritoneal vascular bed which limits platin peritoneal leakage and enhances drug penetration into tumor nodules. Results of a phase I study with the association of IP E and IP cisplatin in patient with refractory peritoneal carcinomatosis has been reported (Molucon-Chabrot et al, Anticancer Drugs, 2006). We conducted a phase I study to evaluate intraoperative IP chemotherapy with the association of cisplatin and escalated dose of E. Methods: 18 patients (pts) with recurrent ovarian cancer were enrolled. The median age was 56 years old (range 42–66). After an optimal cytoreductive surgery, IP chemotherapy was performed during surgery by filling twice the peritoneal cavity with 3 liters of an isotonic saline pre heated at 37°C and 90 mg of cisplatin associated with increasing concentrations of E during 1 hour. Results: E was escalated according to the following dosage: 0, 1, 2, 3 mg/L (3 pts by step). No toxicity was observed during and after intraoperative IP chemotherapy in the first 10 patients. The 2nd patient included in the 3 mg/L level of E experienced a tachycardia ≥ 120/min, ventricular extrasystoles (VES) ≥ 2/min, increase of troponine plasmatic concentration without significant electric sign of cardiac ischemia. The 3rd patient at this level experienced a tachycardia ≥ 120/min with ventricular VES ≥ 2/min and no increase of troponine concentration or electric sign of cardiac ischemia. According to the protocol design, 6 additional patients were included in the lower dose of 2 mg/L of E and no toxicity occurred. One can consider that the recommended dose of E was established. Conclusion: The combination of IP E with IP cisplatin in intraoperative chemotherapy after optimal cytoreductive surgery is feasible. The limiting toxicity was the cardiovascular effect which occurred with 3 mg/L dose of E. A phase II-III study is planned to investigate if IP chemotherapy adds to a second look surgery for the initial treatment of stage III ovarian carcinoma.

No significant financial relationships to disclose.

HER2 overexpression and amplification in advanced ovarian cancer (AOC): Treatment with trastuzumab—A GINECO study

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Background: Variable rates of HER2 protein overexpression and gene amplification have been reported in AOC. Trastuzumab (Herceptin [H]) has been tested only as single agent and has shown a 7% response rate (RR) in heavily pre-treated AOC patients (pts) with 3+ and 2+ HER2 immunostaining (IHC) (Bookman MA et al, J Clin Oncol 2003). GINECO has explored the combination of H with paclitaxel (T) and carboplatin (C) in pts with resistant AOC (< 6 months) and HER2 gene amplification. Methods: 321 AOC pts were centrally screened for HER2 status (243 pts in first-line and 78 relapsing pts). All positive (3+) and doubtful (2+) cases were screened by fluorescence in-situ hybridisation (FISH). Pts with HER2 gene amplification, normal left ventricular ejection fraction (LVEF) and resistant relapse after first or second line of chemotherapy including TC were treated with T (175mg/m2, 3h), C (AUC 5) and H (9mg/kg first course, 6mg/kg subsequent courses) every 3 weeks. Results: Of the 321 cases tested, 22 (6,7%) were HER2+ by IHC and FISH. Only 7 pts (32%) with a median age of 56 (range: 48–70) met the eligibility criteria of the trial. Pts had measurable lesions (n=4) or elevated CA 125 level + non-measurable lesions (n=3). Three pts had complete response (6, 7+ and 24+ months) and 2 had stable disease (3 months). Toxicity was moderate: febrile neutropenia, Gr3 infection, Gr2 neurotoxicity and decrease of LVEF after 23 cycles of H were observed in one patient respectively. Conclusions: HER2 overexpression/amplification is low in advanced ovarian carcinoma (6,7 %). In this small prospective cohort of resistant patients, 3 of 7 have achieved complete remission when adding Trastuzumab to conventional chemotherapy.

No significant financial relationships to disclose.

Second-line chemotherapy with pegylated liposomal doxorubicin and carboplatin is highly effective in patients with advanced ovarian cancer in late relapse: a GINECO phase II trial

BACKGROUND

Platinum-based chemotherapy is standard second-line treatment of patients with advanced ovarian cancer (AOC) in late relapse. Pegylated liposomal doxorubicin (PLD) has significant single-agent activity in this setting. Therefore, we evaluated the use of PLD plus carboplatin in this patient population.

PATIENTS AND METHODS

PLD 30 mg/m(2) followed by carboplatin at area under the curve (AUC) 5 mg.min/ml, repeated every 28 days for a maximum of nine cycles, was administered to 104 women with AOC relapsing >or=6 months after completion of first- or second-line therapy with platinum-taxane-based regimens.

RESULTS

Overall response was 63%, with a 38% complete response, median progression-free survival of 9.4 months, and median overall survival (OS) of 32 months. Grade 3 or 4 neutropenia occurred in 51% of patients, but febrile neutropenia in only 3%. Nonhematologic toxic effects were primarily grades 1 and 2, with low rates of alopecia and neurotoxicity.

CONCLUSIONS

PLD plus carboplatin is highly effective, prolongs OS, and is well tolerated in women with AOC in late relapse previously treated with both platinum and taxanes. Evaluation of this regimen in phase III trials is warranted.

Ant navigation en route to the goal: signature routes facilitate way-finding of Gigantiops destructor

We investigated in laboratory conditions how foragers of the tropical ant Gigantiops destructor develop individually distinctive landmark routes. Way-finding along a familiar route involved the recognition of at least two locations, nest and feeding site, and the representation of spatial relations between these places. Familiar visual landmarks were important both at the beginning and at the end of the foraging journey. A motor routine guided the ants at the start of their foraging path towards the first landmarks, which they learnt to pass consistently on the same side, before taking the next direction. At the last stage of the route, landmark recognition allowed them to pinpoint their preferred feeding site without using distant cues or odometric information. By contrast, ants en route to the goal were not systematically guided by a stereotyped sequence of snapshots recalled at each corresponding stage of the route. Each ant slalomed in an idiosyncratic distinctive way around different midway landmarks from a foraging excursion to the next, which induced a variability of the path shapes in their intermediate parts. By reducing the number of landmark recognition-triggered responses, this economical visuomotor strategy may be helpful in the Amazonian forest where many prominent landmarks are alike.

Phase II trial combining docetaxel and doxorubicin as neoadjuvant chemotherapy in patients with operable breast cancer

BACKGROUND

This study was conducted to assess the antitumour activity of docetaxel in combination with doxorubicin for neoadjuvant therapy of patients with breast cancer.

PATIENTS AND METHODS

Forty-eight women were treated with intravenous doxorubicin 50 mg/m(2) over 15 min followed by a 1-h infusion of docetaxel 75 mg/m(2) every 3 weeks for six cycles. Dexamethasone or prednisolone premedication was allowed. Granulocyte colony-stimulating factor was not allowed as primary prophylaxis. The primary end point was the pathologically documented complete response rate (pathological response).

RESULTS

The mean relative dose intensity calculated for four or more cycles was 0.99 for doxorubicin and 0.99 for docetaxel. Overall, the pathological response rate was 13%. There were 11 complete and 29 partial clinical responses for an overall response rate of 85% [95% confidence interval (CI) 75% to 95%] in the evaluable population (n = 47). Disease-free and overall survival rates were 85% (95% CI 71% to 94%) and 96% (95% CI 85% to 99%), respectively, after a median follow-up of 36.6 months. Grade 3/4 neutropenia was observed in 65% of patients and 17% reported grade 4 febrile neutropenia.

CONCLUSIONS

Docetaxel and doxorubicin is an effective and well-tolerated combination in the neoadjuvant therapy of breast cancer. Future controlled trials are warranted to investigate the best schedules and to correlate response with biological factors.

[Palpable mantel cell lymphoma in the breast]

BACKGROUND

Extranodal involvement is not unusual in mantle cell lymphoma (MCL) which accounts for 6% of non-Hodgkin's lymphomas. Simultaneous localization in the eyelid and in the breast, as observed in our case, is however exceptional.

CASE REPORT

Chronic lymphoid leukemia (CLL) was suspected in a 71-year-old woman with asthenia, a cervical and axillary nodal enlargement and elevated lymphocyte count. Blood immunoflow cytometry analysis, occurrence of rapidly growing tumors involving the two breasts and eyelids and cytogenetic and molecular features led to the diagnosis of MCL. A very good partial remission was obtained with second-line polychemotherapy composed of cytarabin, cisplatin and dexamethasone, but lasted only 3 months after the end of 6 cycles.

DISCUSSION

Primary breast and eyelid lymphomas are rare. Such localizations are exceptional in MCL and are signs of aggressive disease. Before extra-nodal involvement, MCL may simulate banal CLL. Therefore, systematic immunohistochemistry and if necessary molecular analysis are useful for early diagnosis of MCL. Prognosis is particularly poor. Conventional chemotherapy cannot provide cure of MCL and median survival is 48 months. For this reason, high-dose chemotherapy with stem cell graft has to be discussed in young patients. MCL is currently characterized by Bcl1 rearrangement, t(11-14) translocation and cyclin D1 overexpression among small B-cell lymphomas in recent REAL- and WHO-classifications.

Multilocus enzyme analysis in aerobic and anaerobic bacteria using gel electrophoresis-nitrocellulose blotting

An optimized multilocus enzyme electrophoresis method, which involves polyacrylamide-agarose gel electrophoresis followed by electrophoretic transfers on nitrocellulose sheets, was developed for the analysis of enzyme polymorphism in several aerobic and anaerobic bacterial species including Staphylococcus aureus, Streptococcus pneumoniae, S. agalactiae, Klebsiella pneumoniae and K. oxytoca, Clostridium bifermentans and C. sordellii, and Prevotella bivia. Serial electrophoretic transfers (during 5-15 min each) from a single polyacrylamide gel could be achieved for most enzymes studied, and allowed an increased definition of enzyme bands on nitrocellulose as compared to migration gels. Four enzymes, which could not be blotted in such conditions, could still be stained in gels after blotting. Thus, the method allowed the combined analysis of several enzymes after a single gel electrophoresis separation. The analysis of enzyme polymorphism in the various species studied raised the interest of polymorphic loci such as esterase or glutamic-oxaloacetic transaminase for epidemiologic studies. The method characterized a genetic diversity of enzyme loci of S. pneumoniae higher than previously reported, and is thus convenient for the analysis of genetic relationships between related isolates. Since the present method reduces the tediousness of multilocus enzyme electrophoresis and requires experimental conditions that are not specific for the bacterial population studied, it may be proposed for rapid population genetics analysis of a wide variety of bacteria.

[Inverted papilloma of the pyelo-ureteral junction, current literature data]

The authors report the fourth case of inverted papilloma of the ureteropelvic junction since the first description of this lesion in 1963 by Potts and Hirst. In view of the rarity of this lesion and its unusual presentation, they conducted an exhaustive review of the literature concerning inverted papillomas of the upper urinary tract. This proliferative lesion of the urothelium can precede, accompany or follow superficial or invasive urothelial tumours. Rigorous treatment and surveillance are therefore justified to detect an associated tumour. The controversy concerning the benign nature of inverted papilloma has still not been clarified.

[Carotid surgery under loco-regional anesthesia. Early results of 100 recent cases]

A prospective single-centre study was performed to evaluate the safety and efficacy of carotid revascularisation under local anesthesia. Between November 1, 1996 and March 30, 1998, 92 patients underwent surgery for 100 carotid artery stenoses under local cervical block anesthesia. Fifty-eight stenoses were asymptomatic and 42 were symptomatic. Duplex ultrasound scanning showed a tight (n = 17) or very tight carotid artery stenosis (n = 83); angiography showed 19 contralateral carotid artery stenosis and 30 hemodynamically significant stenosis of vertebral and/or subclavian arteries. Cerebral Magnetic Resonance Imaging (MRI) (N = 87) with circle of Willis Magnetic Resonance Angiogram (MRA) (n = 83) detected 29 ischemic defects (33%). Fifteen ischemic defects were found in 58 asymptomatic patients (26%). Circle of Willis was incomplete in 41%. Anesthesia was performed using superficial cervical block (n = 100). Endarterectomy was the most commonly used revascularisation technique in 86 cases with 5 eversion endarterectomies; carotid vein or prosthetic graft was used in 14%. In this study, there was no mortality, and no cardiac or neurologic complications, during the first postoperative month. Twelve patients experienced neurologic intolerance to carotid clamping. This clamping-related ischemia required 4 shunts. All patients with clamping intolerance had a good clinical outcome after revascularisation with no objective or MRI sequelae. Incomplete circle of Willis on MRA was a significant predictive test of clamping intolerance (p < 0.0001). Carotid artery surgery under local anesthesia reduces the cumulative mortality and morbidity rate (TCMM) to a very low level: 0% in this study. These recent results are the modern reference for current carotid artery surgery evaluation.

Endopyelotomy with the Acucise cutting balloon device. Early clinical experience

OBJECTIVES

To evaluate the efficacy of the Acucise balloon cutting device in the treatment of ureteropelvic junction (UPJ) stenosis.

METHODS

Forty-four patients with primary (21) or secondary (23) UPJ stenosis underwent Acucise endopyelotomy between July 1992 and February 1995.

RESULTS

The average operating time was 53 min and the average hospital stay was 6 +/- 4 days. The follow-up schedule included a symptom questionnaire, intravenous urography and diuretic renal scan. Of the 44 patients, 38 have been followed for a minimum of 3 months postoperatively (mean: 12 months, range: 3-39 months). Overall success was achieved in 29 (76%). The procedure was successful in 16 out of 19 cases (84%) with secondary strictures. When the technique was used for the treatment of primary UPJ strictures, the success rate was only 68% (13 out 19). The presence of a large periureteric urinoma was identified as the cause of failure in 2 cases of primary strictures.

CONCLUSION

We recommend the use of the Acucise device as the first-line therapy for treatment of secondary UPJ stenosis (except in the presence of large enclosed stones). We do not approve the use of the Acucise device for treatment of primary UPJ strictures. In primary hydronephrosis, the negative role of periureteric extravasation probably explains the low success rate of 68% (as opposed to 85% for a large series of percutaneous endopyelotomies.

Ureteropelvic invagination procedure for endopyelotomy (Gelet technique): review of 51 consecutive cases

Between 1990 and 1995, we performed 51 endopyelotomies on 38 cases of primary and 13 of secondary obstruction of the ureteropelvic junction (UPJ) using the ureteropelvic invagination technique. Of the 51 patients in the series, 49 have been followed for a minimum of 3 months postoperatively (mean follow-up 16 months). Overall, success was achieved in 38 (77.5%). Endoscopic endopyelotomy was successful in 11 of 13 cases (84.5%) with secondary strictures. When the technique was used for the treatment of primary UPJ stricture, the success rate was only 75% (27 of 36). The presence of a crossing vessel was identified as the cause of failure in five cases of primary strictures; hence, we advocate the use of angiography to identify crossing vessels preoperatively. We recommend the use of the ureteropelvic invagination technique as the first-line therapy for primary hydronephrosis in adults in the absence of a crossing vessel.

VAD-PECC regimen in the treatment of advanced-stage multiple myeloma

PURPOSE

This prospective study was undertaken to evaluate the efficacy of combination chemotherapy with alternating cycles of vincristine, doxorubicin, and dexamethasone (VAD) and prednisone, vindesine, carmustine, and cyclophosphamide (PECC) in poor-risk multiple myeloma (MM).

PATIENTS AND METHODS

Forty-four patients were previously untreated; 36 had been pretreated with an alkylating agent-containing regimen and had refractory or relapsed MM. All previously untreated patients had a high tumor burden at inclusion (stage III according to the Durie and Salmon classification). Logistic regression and the Cox proportional hazards models were used to assess the association between patient characteristics and response rate and survival, respectively.

RESULTS

The overall response rate was 68% for previously untreated patients, compared with 54% for previously treated patients (P = .16). The median survival time for all patients was 28 months: 53 months in previously untreated patients, and 18 months in previously treated patients. Univariate analysis showed that the predictive factors that had a significant affect on survival in the newly diagnosed patients were age, therapeutic response to VAD-PECC, low pretreatment Karnofsky score, high baseline serum beta 2-microglobulin (beta 2M) level, bone marrow impairment, and renal insufficiency at the start of treatment. When these parameters were used as continuous variables in multivariate analysis, three were found to correlate with survival: serum beta 2M, followed by therapeutic response and Karnofsky score. In the previously treated group, only Karnofsky score entered the Cox model.

CONCLUSION

These results indicate that combination VAD-PECC chemotherapy is an effective treatment that results in high response rates and long-term survival in advanced MM.

[Catheter rupture at the site of implantation: a rare accident? Apropos of 2 observations]

Seventy three venous access ports of the same type have been implanted recently in our hospital. We have observed two cases of catheter's rupture. Both accidents show a lot of similarities: material of the same trade mark; same way of implantation: right subclavian vein; rupture before one year; rupture at the point of entry of the subclavian vein; migration of the distal part of catheter; withdrawal of this part by right femoral vein's catheterism. Both broken catheters and another not broken (implanted during more than one year) were tested. It appears that those catheters were weakened, especially around the rupture. The reason is the long-standing compression of the catheter at the narrow space between clavicle and first rib. Then, the rupture of this weakened catheter could have been produced by the high pressure due to injection with small syringes.

[Two-years' experience of ambulatory anesthesia in otorhinolaryngology in children]

Three hundred children were anaesthetized for E.N.T. operations. The anaesthetic consultation took place one week prior to operation. The anaesthetic comprises premedication, inhalation of halothane for infants, or propofol drip for the others with tracheal tubing for 10% of them. Recovery in every case is supervised in the recovery room. There are few setbacks with this method. Eleven children were not accepted for operation for sociological or medical reasons (Willebrand diseases) and only 3 had to remain in hospital until the following day due to slow recovery from anaesthetic.

[T lymphoma of the nasopharynx, a rare entity. Apropos of a case]

We report one case of nasal T-cell lymphoma (NTL) that we studied histologically and with a panel of monoclonal antibodies. It is a rare etiology of the so-called lethal midline granuloma. The diagnosis of NTL if often difficult because of spreading necrosis, cellular polymorphism and necessity of getting frozen snap sections for immunohistochemical techniques. We describe histological, immunohistochemical features of NTL and its usual follow up. Then we compare them with those of malignant lymphomas of the Waldeyer's ring which are very different although they are located very near to NTL. These differences raise the hypothesis of a possible role of the local environment.

Unusual approaches for insertion of the Greenfield vena cava filter: the value of its approach through the jugulosubclavian junction

During the last four years, we have attempted 249 insertions of the Greenfield inferior vena cava filter using the right internal jugular vein. This approach was impossible in 31 patients (12.5%). Our first alternative was the insertion of the filter through the venous junction between the right internal jugular and right subclavian veins. If this latter technique was not possible we attempted the insertion of the Greenfield filter through the left internal jugular vein before using the retrograde femoral route which is associated with high morbidity. By these techniques we have been able to reduce the number of patients in whom it is impossible to achieve mechanical endocaval partial interruption to 2.4%.