Adjuvant Systemic Therapies in Patients with Colorectal Cancer: An Audit on Clinical Practice in Italy

Aims and Background

Rarely are conclusions from clinical trials summarized in international consensus conferences and promptly transferred to patient care. The adjuvant therapy for colorectal cancer used in daily clinical practice in Italy is described and compared with the recommendations of the 1990 NIH Consensus Conference.

Patients and Methods

We audited prescriptions of adjuvant systemic therapies for Italian colorectal cancer patients in 82 centers during a fixed one-week period.

Results

Among 434 patients receiving adjuvant chemotherapy there were 139 (42.5%) colon cancer patients with N- and 169 (51.7%) with N+ regional nodal involvement. Treatment at academic centers, a young age, T4 and a low total number of lymph nodes removed at surgery were the factors potentially justifying the decision for adjuvant chemotherapy in stage II colon cancer patients. The most common chemotherapy used was a bolus of 5-fluorouracil/folinic acid for 6 months (75.8%). Adjuvant radiotherapy was not administered to 37 (38.5%) of 96 patients with stage II and III rectal cancer.

Conclusions

The study shows that a substantial proportion of patients on adjuvant treatment at a certain time point in a large enough sample of Italian centers are stage II (potential over-treatment) and that an under-treatment of stage II and III rectal cancer patients (lack of radiotherapy) occurs too often in daily clinical practice in this country.

Pancreatic cancer with liver metastases in a pregnant patient: case report and review of the literature

In this case report, the authors discuss clinical presentation, surgical procedure and early results of chemotherapy of pancreatic carcinoma with liver metastases diagnosed a few days after delivery. Pancreatic adenocarcinoma occurs infrequently in pregnant and childbearing women: only ten cases have been reported in the literature. The early diagnosis of pancreatic cancer is difficult because symptoms appear when cancer is about to reach an advanced stage. In pregnancy, it is even more difficult because symptoms like dyspepsia, vomiting and epigastric pain may result confusing. The authors outline the difficulties in diagnosis and treatment of this kind of disease during pregnancy.

Adjuvant chemotherapy in the treatment of colon cancer: randomized multicenter trial of the Italian National Intergroup of Adjuvant Chemotherapy in Colon Cancer (INTACC)

BACKGROUND

To determine whether the addition of leucovorin to the combination 5-fluorouracil plus levamisole prolongs disease-free survival and overall survival in patients with radically resected colon cancer (Dukes' B(2-3) and C).

PATIENTS AND METHODS

Patients (1703) were accrued between March 1992 and February 1995 in a large-scale clinical trial within five Italian cooperative groups. After stratification for center, patients were randomized as follows: arm A, 5-fluorouracil [450 mg/m(2) intravenous (i.v.) bolus on days 1-5] and levamisole (150 mg orally for 3 days, every 14 days for 6 months) versus arm B, 6-S-leucovorin (100 mg/m(2) i.v. bolus on days 1-5) followed by 5-fluorouracil (370 mg/m(2) i.v. bolus on days 1-5), plus levamisole (as arm A), every 4 weeks for six cycles.

RESULTS

After a median follow-up of 6.4 years no significant difference was seen for either disease-free survival (58% versus 60%, not significant) or 5-year overall survival (68% versus 71%, not significant), respectively. Gastrointestinal toxicity (World Health Organization grade 3/4) was more frequent in arm B (8% versus 18%, not significant).

CONCLUSIONS

In this trial the schedules used showed no statistically significant differences in terms of disease-free survival or overall survival in the treatment of colorectal cancer.

Pre-anesthesiological assessment in paediatric cataract surgery

The authors underline the importance of accurate pre-anesthesiological assessment in children undergoing cataract. The alteration is frequently related to many genetic, metabolic and infectious pathologies that could interfere in anesthesia management whatever surgery is requested. Some possibly responsible congenital syndromes and related alterations are mentioned, particularly focusing on Down's syndrome.

Neuro- and ototoxicity of high-dose carboplatin treatment in poor prognosis ovarian cancer patients

BACKGROUND

Hematopoietic toxicity of high-dose carboplatin (HD-CBDCA) chemotherapy can be managed effectively with autologous blood cell support, but no conclusive data are available on its neuro- and ototoxicity.

PATIENTS AND METHODS

We determined the neuro- and ototoxicity of HD-CBDCA in 10 patients affected by advanced ovarian cancer. HD-CBDCA was delivered as 24-hour continuous infusion or as 5-day schedules. Each patient underwent an extended clinical and instrumental neurological and otological evaluation before, during and after treatment.

RESULTS

After HD-CBDCA only 1 patient had a clinically-evident peripheral neuropathy, while 3 additional patients had only distal paresthesias. Neurophysiological examination evidenced mild, although diffuse, sensory nerve impairment. Motor nerve impairment was also occasionally observed. All the sensory and motor pathological changes had a favorable course during the follow-up period. Ototoxicity was more severe than neurotoxicity and, in one case it was dose-limiting and audiologic impairment tended to remain constant also in the follow-up period.

CONCLUSIONS

HD-CBDCA treatment can be tolerated by most of the patients, but careful monitoring of neuro- and, especially, ototoxicity should be planned.

High-dose folinic acid and 5-fluorouracil alone or combined with hydroxyurea in advanced colorectal cancer: a randomized trial of the Italian Oncology Group for Clinical Research

Patients with histologically confirmed advanced colorectal cancer were randomized to receive folinic acid (FA; 500 mg/mq in 2-hour intravenous infusion) and 5-fluorouracil (5FU; 600 mg/mq given as an intravenous bolus 1 hour after FA), beginning every week for 6 weeks, followed by a 2-week rest period, either without hydroxyurea (HU, arm A) or with HU (35 mg/kg per day) given orally in three administrations (every 8 hours) starting 6 hours after 5FU administration (arm B). Six weekly doses were considered one course. One hundred eighty-two patients were randomized in this trial and 162 (89%) were evaluable for response: 81 patients in arm A and 81 patients in arm B. Objective response was observed in 18 (one complete response and 17 partial responses) of 81 evaluable patients (22%; 95% confidence interval, 13-31%) in arm A, and 24 (nine complete responses and 15 partial responses) of 81 patients (30%; 95% confidence interval, 20-40%) in arm B. There was no difference in terms of median time to progression and median survival. Gastrointestinal toxicity was the most frequently observed toxicity in both arms. The double modulation of 5FU, FA plus HU does not appear to be better than the classic 5FU plus FA schedule. This trial confirms that 5FU and FA reached a plateau of 20% to 30%.

Second-look laparotomy in the management of fallopian tube carcinoma

OBJECTIVE

To evaluate the role of second-look laparotomy following platinum-based combination chemotherapy in patients with fallopian tube carcinoma.

METHODS

A retrospective chart review was conducted on 21 patients with tubal carcinoma who underwent second-look laparotomy following cytoreductive surgery and platinum-based combination chemotherapy.

RESULTS

Thirteen patients (62%) were found to be free of disease at second-look operation. Neither stage nor grade were predictive of findings at second-look procedure. The absence of gross residual disease following primary surgery was the only predictor of disease-free status at second-look laparotomy (p < 0.01). With a mean follow-up of 49 months among the survivors, four (31%) of the patients with negative second-look laparotomy have had a recurrence. The median survival following a positive second-look laparotomy was 18 months (range 5-42 months).

CONCLUSION

Second-look laparotomy provides useful prognostic information in patients with tubal carcinoma. The high rate of recurrent disease after negative second-look laparotomy, and the lack of an effective second-line treatment in patients with persistent disease, represent major criticisms of this procedure.

Neurotoxicity and ototoxicity of cisplatin plus paclitaxel in comparison to cisplatin plus cyclophosphamide in patients with epithelial ovarian cancer

PURPOSE

To compare the neurotoxicity and ototoxicity of combination cisplatin plus paclitaxel versus cisplatin plus cyclophosphamide using extensive clinical and instrumental evaluation.

PATIENTS AND METHODS

Forty-six of 51 consecutive patients affected by-epithelial ovarian cancer seen in our institution between October 1994 and August 1995 entered the study. After randomization, they were assigned to receive cisplatin 75 mg/m2 every 3 weeks associated with cyclophosphamide 750 mg/m2 (CC group, n = 22) or paclitaxel 175 mg/m2 over a 3-hour infusion (CP group, n = 24). Treatment was repeated six times in 43 patients and nine times in 25. Before treatment and after three, six, and nine courses of chemotherapy, patients underwent clinical and instrumental neurologic and otologic examinations.

RESULTS

Mild sensory impairment was evident even after only three courses of both treatments and signs and symptoms were more severe at the end of treatment. On clinical grounds only, it was possible to demonstrate after six and nine courses a difference between CC and CP treatment, due to the involvement in some CP patients of pain and thermal sensory modalities. However, the overall severity of the neuropathy was similar. Audiometric parameters demonstrated a more negative outcome after treatment in CC compared with CP patients. However, the different severity of the involvement was closely correlated to this initial difference in audiologic performance.

CONCLUSION

Up to nine courses of chemotherapy, the CC and CP schedules are similar in terms of severity of neurotoxicity and ototoxicity when patients are evaluated during and immediately after treatment. With the doses used in our study, these toxicities are not dose-limiting. Our results suggest that most of the toxic effects observed during the treatment were due to cisplatin.

Depressive symptoms and quality of life in home-care-assisted cancer patients

To examine the prevalence of depressive symptoms and its relationship with quality-of-life domains in home-care cancer patients at an advanced stage of illness, 86 patients were given psychological tests for depression (Hospital Anxiety Depression Scale) (HAD) and quality of life (EORTC-QLQ-C30) 1 week after admission to the home-care program. Using a proper cut-off score on the HAD-Depression subscale, depressive symptoms were reported by 45% of the patients. The quality of life of depressed patients was more affected than non-depressed patients in the social, emotional, cognitive, and physical domains. Significant correlations were found between depression scores and impairment in most quality-of-life areas. These findings support the importance of depression and quality-of-life evaluation in patients with advanced cancer who are followed in a home-care setting. This evaluation is needed to provide patients, their families, and caregivers with appropriate psychosocial interventions.

Expression of the 67 kD laminin receptor in human ovarian carcinomas as defined by a monoclonal antibody, MLuC5

Previous immunohistochemical data from our laboratory have demonstrated that expression of the 67 kD laminin receptor (67LR), a cancer-associated, high-affinity laminin-binding protein, is upregulated in ovarian carcinoma cells compared with normal serosal cells, and that this increased expression in cancer cells could be related to patient outcome. The aim of this study was to validate MLuC5, a monoclonal antibody that recognises the 67LR, as a tool to perform future immunohistochemical studies on larger populations of ovarian carcinoma patients. Expression of the 67LR was determined in 51 primary human ovarian carcinoma samples using immunohistochemistry and MLuC5. The 67LR was detected in ovarian carcinoma cell clusters of variable extent. Analysis of the data determined that 67LR expression was significantly increased in the samples from patients with disease progression, compared with those with no evidence of disease after completion of primary therapy, and in pooled grade 2 and 3 tumours compared to borderline and grade 1 tumours (P < 0.05, chi-squared test). No other significant correlation between 67LR expression and other clinicopathological parameters could be established. These data suggest that the 67LR is correlated to ovarian tumour progression. Detection of the 67LR using this monoclonal antibody could constitute an interesting parameter in prognosis determination of ovarian cancer.

Salvage therapy with ifosfamide and mitoxantrone in advanced ovarian cancer

OBJECTIVE

To evaluate the anti-tumour activity and toxicity of ifosfamide (5 g/m2 continuous infusion) and mitoxantrone (10 mg/m2) given in combination every 3 weeks in patients with ovarian cancer resistant to at least two previous regimens which included platinum.

PATIENTS AND METHODS

Additional eligibility criteria were an ECOG performance status < or = 2 and measurable disease. Of 47 patients entered in the study, 8 were defined as platinum-resistant and 39 as potentially sensitive according to Markman's criteria. Thirty-five patients had also received paclitaxel as last treatment before entering this study. Tumour response was evaluated every three cycles.

RESULTS

One complete and 11 partial responses were reported, for an overall response rate of 25% (95% CI: 14%-40%). Three of the partial responders were resistant to platinum. None of the 7 partial responders pretreated with taxol had responded to it. The overall median survival was 11 months. Neutropenia G4 was reported in 18 patients (42%) with hospitalisation because of febrile neutropenia in 3 of them.

CONCLUSIONS

In patients with ovarian cancer failing at least 2 previous therapies including platinum, the combination of ifosfamide and mitoxantrone has shown an antitumour activity comparable to that of paclitaxel, with acceptable toxicity. Objective responses were reported also in patients failing paclitaxel, suggesting a lack of cross resistance.

Detection of abnormal intrauterine vascularization by color Doppler imaging: a possible additional aid for the follow up of patients with gestational trophoblastic tumors

Uterine morphology assessed by transvaginal ultrasound and the hemodynamics of intratumoral vessels assessed by color Doppler ultrasound were prospectively correlated with the clinical outcome of 25 patients with trophoblastic tumors. Twenty patients were followed without treatment (observation group) and 16 achieved complete local resolution. The four subjects with local persistence were combined with five patients referred from other institutions and received chemotherapy (treatment group). In the observation group both techniques had 100% accuracy in predicting local resolution or local persistence. Persistence was predicted 1-3 weeks before the increase of beta-human chorionic gonadotropin (beta-hCG) levels, whereas resolution was observed up to 8 weeks before the disappearance of beta-hCG. In one patient normal uterine morphology and vascularization in the presence of elevated hCG levels was associated with extrauterine spread. In the treatment group, normal uterine ultrasound morphology and negative color Doppler results had 100% negative predictive value. False-positive results were observed in two cases. We conclude that ultrasound evidence of abnormal uterine morphology or persistent vascularization on color Doppler examination with persistent hCG levels is indicative of local persistence. Normal uterine morphology with negative color Doppler results may be associated with extrauterine spread.

Peripheral neurotoxicity of taxol in patients previously treated with cisplatin

BACKGROUND

Taxol is a new anticancer drug that acts as a tubulin polymeration enhancer. Its major toxicities are myelosuppression, hypersensitivity, and mucositis, but it also induces peripheral nerve damage. The use of taxol has recently been proposed for platinum-resistant cancers, but in these cases there is a possibility of cumulative toxicity in the peripheral nervous system.

METHODS

Twenty-two patients affected by a relapse of cisplatin-treated ovarian cancer were examined clinically and neurophysiologically to determine the evolution of taxol-induced peripheral somatic and autonomic neurotoxicity and the possible cumulative effect of a combination of taxol and cisplatin. Each patient was examined before, during, and after taxol treatment (using a dose of 135 or 175 mg/m2 in 3 hours every 3 weeks).

RESULTS

No patients were excluded from the study because of unacceptable toxicities of any kind. The serial examinations demonstrated that taxol induced onset of (or worsening of preexisting) neuropathic symptoms and signs in almost all the patients. The features were those of a distal, symmetrical, sensory polyneuropathy due to an axonopathy. Motor nerves and the autonomic nervous system were unaffected. Taxol neurotoxicity appeared early in the course of the treatment (i.e., after three courses) and was not severely disabling. In most cases after the early onset of peripheral neuropathy, stabilization of this side effect occurred.

CONCLUSIONS

Considering the low doses of taxol used in this study, the sensory nerve damage was unexpectedly severe. It appears that a cumulative, but not dose-limiting, neurotoxic effect occurs using taxol in patients previously treated with cisplatin.

Bleomycin, ifosfamide and cis-platin chemotherapy in recurrent and persistent cervical cancer, a prospective study

Thirty patients with histologically proven recurrent or persistent squamous cell cervical carcinoma were treated with chemotherapy, consisting of a combination of bleomycin, ifosfamide and cis-platin (BIP). All patients were evaluable for response. An objective response was seen in nine of the 30 patients (30%): complete in two (6.7%) and partial in the other seven (23.3%). A total of 39 tumor sites was treated: five responses were observed in 26 irradiated areas (19%), whereas seven responses were observed in 13 nonirradiated areas (53.8%). Side-effects were mainly nausea, vomiting, alopecia, myelosupression, fever and impaired renal function. Encephalopathy was recorded in four patients (severe in one). No patient died from the toxic effects of chemotherapy. The results indicate that BIP is an active combination in recurrent and advanced cervical carcinoma, with acceptable toxicity; however, this combination failed to prove any superiority over other single or multi-drug treatments proposed in the last decade.

Red blood cell sodium heteroexchange in familial primary hypertrophic cardiomyopathy

The hallmark of primary hypertrophic cardiomyopathy is an inappropriate myocardial hypertrophy, linked to myofibril disarray of the left ventricle. Its variable clinical expression may be due to genetic heterogeneity and variable penetrance. Since we have recently shown that abnormalities of cation transport in the erythrocytes are associated with cardiac hypertrophy in essential hypertensives and insulin-dependent diabetics, we have investigated the relationship between cardiac anatomy and function and red cell Li+/Na+ and Na+/H+ exchange in 33 relatives of a patient who died of cardiac failure and was found to have a primary hypertrophic cardiomyopathy at autopsy. According to echocardiographic examination, 11 members of the family also had a hypertrophic cardiomyopathy, with a family distribution compatible with autosomal dominant genetic transmission and variable penetrance. Red cell Li+/Na+ and Na+/H+ exchange were not significantly different in the affected members as compared to the unaffected, but in the former, after correction for potentially confounding variables, interventricular septum thickness was positively correlated to Na+/H+ exchange and diastolic function (Area E/Area A and Vmax E/Vmax A) negatively correlated to Li+/Na+ exchange. Since a generalized overactivity of the cell membrane Na+/H+ exchange, reflected by increased Na+/H+ and Li+/Na+ exchanges in the red cells, could favour cellular growth and diastolic dysfunction, our data suggest that abnormalities of cell membrane cation transport could play a role in the phenotypic expression of hypertrophic cardiomyopathy.

Overexpression of p185 is not related to erbB2 amplification in ovarian cancer

BACKGROUND

While in breast cancer the amplification and overexpression of the erbB2 gene has been reported in numerous studies and found to be correlated to poor prognosis, information about this oncogene with respect to ovarian cancer is still limited. A recent study reported that approximately 30% of tumor biopsies from ovarian cancer patients exhibited erbB2 amplification and overexpression and suggested that the overexpression of this oncogene is an indicator of bad prognosis in ovarian cancer. The purpose of our studies was to investigate amplification of the erbB2 gene, the levels of erbB2 m-RNA and the erbB2 product (p185) in ovarian cancer, and the correlation between these findings and the pathological and clinical features.

RESULTS

Amplification of the erbB2 gene was investigated by Southern blot analysis in 75 samples from 62 patients; mRNA levels were evaluated by Northern blot analysis in 58 samples from 48 patients; and p185 was determined by immunohistochemistry in 65 samples from 65 patients. The erbB2 gene was amplified in only one case (1.6%), and a marked increase in erbB2 mRNA was found only in the same case. Staining for p185 was positive in 12 cases (18.5%). The staining was always confined to the cytoplasm except in the case that showed amplification of erbB2 in which p185 was localized in the membrane. No correlation was found between p185 positivity and pathological and clinical features or response to chemotherapy. Western blot analysis showed that the molecular weight of p185 in positive ovarian cancer cells was approximately 10 KDa lower than in breast cancer.

CONCLUSION

In contrast to breast cancer, in ovarian cancer the amplification of erbB2 appears infrequent. The levels of p185 detected by immunohistochemistry were not related to the amplification of the gene or to the increase in mRNA, suggesting the possibility of a longer half-life of the protein in the positive cases. The finding that erbB2 product in ovarian cancer is mostly localised in cytoplasm and not in the membrane as in breast cancer and that it has a lower molecular weight than the p185 in breast cancer suggest that this oncogene plays a different biological role in these two neoplasms.

Early and short-term complications after US-guided puncture of gynecologic lesions: evaluation after 1,000 consecutive cases

PURPOSE

To ascertain the complication rate associated with ultrasound (US)-guided puncture of gynecologic lesions.

MATERIALS AND METHODS

Between 1986 and 1992, 878 transabdominal and 122 transvaginal US-guided punctures of gynecologic lesions were performed in 893 patients. Most of the procedures were performed in adnexal cysts (n = 838); the rest, in solid tumors (n = 66), mixed tumors (n = 56), or lymphoceles, abscesses, or fluid collections (n = 40). No anesthesia or antibiotic prophylaxis was routinely used.

RESULTS

No life-threatening complication was recorded. Early complications (defined as complications that occurred within 24 hours after puncture) were recorded in 31 patients and consisted mainly of transient vagal symptoms or pain. Short-term complications (within 5 days after puncture) were recorded in 10 patients, six of whom required surgery.

CONCLUSION

US-guided puncture of gynecologic lesions is safe in selected patients. Complication rates depend on the type of lesion and are very high in dermoid cysts, which should not be punctured, and extremely low in serous cysts, solid tumors, and mixed tumors.

Low-dose oral etoposide in epithelial cancer of the ovary

AIMS

To evaluate antitumour activity, toxicity, pharmacokinetics, and the pharmacodynamic relationship with neutropenia of low-dose oral etoposide (E) in patients (pts) with epithelial cancer of the ovary previously treated with cisplatin.

PATIENTS AND METHODS

Eighteen pts receiving 50 mg daily of oral E for 21 days every 4 weeks. CBC with differential repeated every week. E plasma levels determined by HPLC method (sensitivity limit: 0.1 microgram/ml) with evaluation during the first cycle of bioavailability and weekly 24-hour drug concentrations.

RESULTS

Among 17 evaluable pts, 1 partial remission of 9 months. Dose-limiting neutropenia of high inter-patient variability. Mean bioavailability value of 75%, ranging from 44% to 100%. No correlation between mean 24-hour E plasma levels and ANC nadir or relative decrease of ANC during the first cycle.

CONCLUSIONS

Low-dose oral E is ineffective as salvage treatment in epithelial cancer of the ovary. The large variability of neutropenia requires a careful hematological monitoring to avoid severe myelosuppression.

Effects of canrenoate on red cell sodium transport and calf flow in essential hypertension

The effects of potassium canrenoate (100 mg/day, orally for 1 month) on blood pressure, calf blood flow at rest and after ouabain (0.5 mg intravenous bolus), and red cell Na homeostasis were investigated in 15 patients (7 men, 8 women, aged 18 to 63) with essential hypertension and without peripheral vascular diseases. On placebo, acute intravenous ouabain administration significantly and transiently reduced calf flow and increased calf vascular resistance without affecting blood pressure. Canrenoate significantly decreased blood pressure (from 159 +/- 21/105 +/- 9 mm Hg to 141 +/- 14/94 +/- 10, P < .05) and the rise of calf resistance after intravenous ouabain bolus. The latter effect was variable, since it was inhibited almost completely in 8 patients and unaffected in the others. In the patients in whom exogenously administered ouabain was antagonized, canrenoate diminished blood pressure through vasodilation and heightened the red cell Na/K pump. None of these parameters changed significantly in the other patients. Thus these data suggest that the fall in vascular resistance induced by canrenoate is mediated, in part, by the antagonism of endogenous ouabain-like factors.

Red blood cell Li+/Na+ exchange in patients with diabetic nephropathy and essential hypertension: therapeutic implications

Patients who develop diabetic nephropathy, one of the leading causes of end-stage renal diseases in Western communities, have an increased red cell Li+/Na+ countertransport (CT). Li+/Na+ CT is a membrane function which exchanges intracellular Li for extracellular Na in vitro. High Li+/Na+ CT reflects abnormal kinetic properties of red cell membrane Na/H exchange. A widespread abnormality of Na/H exchange could play a major role in the pathogenesis of diabetic nephropathy as well as of cardiovascular diseases since Na/H exchange is involved in the regulation of cell pH and cell volume; in the cellular response to hormones, mitogens, and growth factors; and in the renal reabsorption of Na and bicarbonate. Li+/Na+ CT is under genetic control and raised in a subgroup of patients with essential hypertension. Among these patients, high Li+/Na+ CT is associated with increased glomerular filtration rate, filtration fraction, proximal fractional Na reabsorption, microalbuminuria, plasma renin activity, and kidney and cardiac volume. Increased Li+/Na+ CT is often associated with hyperlipidemia, hyperuricemia, reduced insulin sensitivity, and obesity. The whole of these observations may explain why patients with diabetes or essential hypertension and increased Li/Na CT are at risk of early renal and cardiac impairment.

Fluorouracil-alone versus high-dose folinic acid and fluorouracil in advanced colorectal cancer: a randomized trial of the Italian Oncology Group for Clinical Research (GOIRC)

One hundred eighty-one patients with measurable recurrent or metastatic colorectal cancer, who had not received prior chemotherapy, were randomized in a prospective controlled trial to receive 5-fluorouracil (5FU), 13.5 mg/kg, for five days (arm A) or high-dose folinic acid [Cyanamid-Lederle, Italy] (FA), 200 mg/m2, for five days and 5FU, 400 mg/m2 for five days (arm B). The treatments were repeated every four weeks. One hundred fifty-five patients were evaluable for response. The two arms were balanced for all potential prognostic factors studied. The response rate (CR+PR) was 18% in the 5FU arm and 16% in the 5FU plus FA arm. Median duration of response was 56 weeks for 5FU alone and 42 weeks for the combination (p = 0.48). Median time to failure (TTF) was 20 weeks for arm A and 21 for arm B (p = 0.62). Median survival was 62 weeks on the 5FU arm and 53 weeks on the FA plus 5FU arm (p = 0.14). Dose intensity (DI) delivered was the same in both arms. Diarrhea and mucositis were the most frequent adverse reactions in arm B; 20% of the patients in arm A and 38% of those in arm B experienced diarrhea (p = 0.008). Mucositis occurred in 34% of patients in arm A and 42% in arm B (p = 0.04). In general nausea and vomiting were moderate. Hematological toxicity was more severe in patients treated with 5FU alone: 31% in arm A and 14% in arm B developed leukopenia (p = 0.015). In the combination arm one patient died due to gastrointestinal and hematological toxicity after the seventh cycle. This study indicates that, in advanced colorectal cancer, the combination of high-dose FA and 5FU is not superior to 5FU alone when utilized at standard high-dose intensity.

Erythrocyte Li+/Na+ and Na+/H+ exchange, cardiac anatomy and function in insulin-dependent diabetics

It has been proposed that an increased activity of cell membrane Na+/H+ exchange, mirrored by increased erythrocyte Li+/Na+ exchange, may facilitate cell hypertrophy and hyperplasia. Patients with insulin-dependent diabetes mellitus may develop a specific cardiomyopathy with systolic and diastolic abnormalities and increased thickness of the left ventricle. Therefore, we have investigated the relationships between erythrocyte Li+/Na+ and Na+/H+ exchange and echocardiographic parameters in 31 male insulin-dependent diabetics (aged 17-68), in good metabolic control. Three had untreated mild hypertension. In all patients the urinary albumin excretion rate was less than 200 micrograms min-1. Ten patients had a Li+/Na+ countertransport higher than 0.37 mmol l-1 cell h-1, the upper normal limit for our laboratory (0.49 +/- 0.10, mean +/- SD). In comparison with the patients with normal countertransport, they had increased interventricular septum thickness and relative wall thickness (h/r). End diastolic volume and cardiac index were reduced while blood pressure and urinary albumin excretion rate were similar. In the whole study group, interventricular septum thickness was significantly correlated to Li+/Na+ exchange (r = 0.61, P less than 0.001) and Na+/H+ exchange (r = 0.35, P less than 0.05), independently of the effect of age and blood pressure. Posterior wall thickness was correlated to Li+/Na+ exchange (r = 0.38, P less than 0.05) and h/r to Li+/Na+ exchange (r = 0.41, P less than 0.05) and to Na+/H+ exchange (r = 0.44, P less than 0.05). Li+/Na+ exchange was negatively correlated to cardiac index (r = -0.37, P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Cisplatin-induced peripheral neurotoxicity is dependent on total-dose intensity and single-dose intensity

The authors prospectively evaluated the effects of three different schedules of cisplatin (DDP) administration in 60 patients with advanced epithelial ovarian cancer. The individual total dose of DDP was 450 mg/m2 in all three groups, and the anti-cancer response at the end of treatment was similar for the different regimens. The clinical and neurophysiologic results confirmed that axonal sensory neuropathy occurred after the standard administration of DDP (75 mg/m2 in 3-week cycles) and probably not only the peripheral, but also the central sensory pathway, was involved. Although the total dose of the drug was identical, the two less conventional schedules were less neurotoxic. These results suggest that not only the total-dose intensity, but also the single-dose intensity are relevant in the onset of DDP-induced sensory neuropathy; therefore, the use of less neurotoxic schedules may prevent or reduce sensory nerve damage.

The incidence and course of paraneoplastic neuropathy in women with epithelial ovarian cancer

Sensorimotor polyneuropathy is the most common of the paraneoplastic syndromes involving the nervous system. Its incidence is high (more than 50%) in the patients undergoing neurophysiological investigation, and it is considered to be more frequent in subjects with lung and breast cancers. In this study we evaluated a series of 58 women with epithelial ovarian cancer at FIGO stages I and III. The aim of the study was to assess the incidence and characteristics of peripheral nerve involvement during the course of the disease both clinically and neurophysiologically. Our results suggest that in women with epithelial ovarian cancer (1) the incidence of subclinical polyneuropathy is high; (2) sensory involvement is predominant in stage I, but motor involvement is frequent in stage III; and (3) the incidence of peripheral nerve involvement increases with progression of the cancer.

Cis dichlorodiammine platinum induced DNA interstrand cross-links in primary cultures of human ovarian cancer

We quantified and examined the kinetics of DNA interstrand cross links (DNA-ISC) caused by Cis dichlorodiammine platinum (DDP) using the method of alkaline elution in 58 highly purified human ovarian tumours growing in primary culture. A large heterogeneity in both the quantity and kinetics of DDP induced DNA-ISC was observed in cultures derived from neoplasms of different patients and from different lesions of the same patient. In the majority of cases. DNA-ISC lasted for prolonged time intervals after 1 h drug exposure, being significantly repaired only 48 or 72 h following drug washout. The persistence of DNA-ISC is probably due to a prolonged formation of these lesions for up to 24 h as assessed by the change in the repair kinetics that occurred after preventing new DNA-ISC formation by quenching of monoadducts with thiourea. The inefficient repair of DDP monoadducts appears therefore to be a possible reason for the permanence of DNA-ISC. These studies suggest that the long permanence of DNA-ISC in human ovarian cancer could be the basis for the high selectivity of DDP for this human malignancy.

Red blood cell Na+/H+ and Li+/Na+ exchange in patients with essential hypertension

The increased red blood cell Li+/Na+ exchange found in a subgroup of patients with essential hypertension (EH) may reflect an increased activity of the Na+/H+ exchange. The maximal velocity of the red cells' Na+/H+ (Na+ influx promoted by an outward H+ gradient) and Li+/Na+ (Li+ efflux promoted by external Na+) exchange were therefore measured in 41 EH and in 21 normotensive controls (NT). Both transporters were significantly higher in EH than in NT (74 +/- 39 mmol/L cell x h v 43 +/- 27 for the former, P less than .03, and 0.35 +/- 0.16 v 0.26 +/- 0.10 for the latter, P less than .05). Even though more than 100 times faster, Na+/H+ exchange was weakly but significantly correlated to Li+/Na+ exchange (r = 0.29, P less than .05). Proximal tubule Na+ reabsorption (fractional renal Li+ reabsorption) was significantly greater in EH than in NT (0.78 +/- 0.07, n = 32, v 0.73 +/- 0.06, n = 10, P less than .05) but it was not correlated to either the red cells' Na+/H+ or Li+/Na+ exchanges. Therefore, hyperactivity of Na+/H+ exchange in EH may play a role in blood pressure elevation through mechanisms other than stimulation of renal Na+ reabsorption.

[Volume of the extracellular liquid and renal function during short-term administration of angiotensin converting enzyme inhibitors in essential hypertension]

Short term angiotensin converting enzyme inhibition may induce a transient salt and water retention in patients with hypertension or heart failure. To verify the glomerular and tubular effects of short term converting enzyme inhibition, thirteen patients with mild to moderate essential hypertension (WHO I-II) were treated orally either with perindopril (4 mg o.d.) or captopril (25 mg b.i.d.) for one week. Both drugs reduced supine mean blood pressure significantly (p less than 0.01) (perindopril from 126 +/- 11 to 108 +/- 7 mmHg, mean +/- SD, and captopril from 132 +/- 12 to 121 +/- 16). Plasma volume (radio-iodinated albumin space) was unchanged while mean extracellular fluid volume (inulin space) increased although not significantly (from 5.05 +/- 1.32 l/sqm to 5.71 +/- 2.21 with perindopril and from 4.96 +/- 2.6 to 5.6 +/- 1.7 with captopril). Sodium clearance decreased (from 1.4 +/- 0.6 to 1.1 +/- 0.5 ml/min 1.73 sqm with perindopril, p less than 0.05, and from 0.97 +/- 0.44 to 0.88 +/- 0.51 with captopril, n.s.). In 9 patients (6 on captopril and 3 on perindopril) extra-cellular fluid volume increased simultaneously with reduction in glomerular filtration rate and in proximal tubule sodium re-absorption as well as an increase in distal tubule sodium reabsorption. In these patients the changes in proximal and distal tubule sodium reabsorption were significantly (p = 0.05) different from those of the patients with no extra-cellular fluid expansion.(ABSTRACT TRUNCATED AT 250 WORDS)

[Erythrocyte Li/Na countertransport and correlated variables in a randomized sample of population]

A genetically determined alteration of the cell membrane sodium metabolism may play a role in the pathogenesis of essential hypertension. The most consistent finding in patients with essential hypertension is an increased red blood cell Li/Na exchange (countertransport). It is genetically determined but it is also associated to potentially confounding variables (body weight, race, age and so on). The present study investigates the relationship between red cell Li/Na countertransport and various potentially confounding variables in a random sample of the population. It shows that this membrane cation transport system is increased in males compared to females and significantly correlated to body mass index in males and to blood pressure, alcohol consumption and, negatively, to urinary calcium excretion in females. Since body weight and alcohol consumption are correlated to blood pressure in several epidemiological studies, it can be hypothesized that they influence blood pressure control through an alteration of the cell membrane sodium transport.

A model for investigating the effect of drugs on the peripheral sympathetic nervous system in man

A model for assessing the effect of sympatholytic drugs on the peripheral sympathetic nervous system in man is described. Guanethidine, a sympatholytic drug, and the vehicle have been used to explore the model which is based on the Bier block. Sympathetic activity was assessed by measuring: (i) palmar sweating; (ii) skin temperature; (iii) radial/brachial pressure index; (iv) hand blood flow; and (v) vasoconstrictor ice response of hand blood flow. Neither the tourniquet nor the vehicle had any effect on sympathetic activity whereas guanethidine produced significant changes in skin temperature (P less than 0.05), hand blood flow (P less than 0.001) and the vasoconstrictor ice response (P less than 0.002), illustrating the usefulness of the model.