Real-world ANASTASE study of atezolizumab+nab-paclitaxel as first-line treatment of PD-L1-positive metastatic triple-negative breast cancer

The combination of atezolizumab and nab-paclitaxel is recommended in the EU as first-line treatment for PD-L1-positive metastatic triple-negative breast cancer (mTNBC), based on the results of phase III IMpassion130 trial. However, 'real-world' data on this combination are limited. The ANASTASE study (NCT05609903) collected data on atezolizumab plus nab-paclitaxel in PD-L1-positive mTNBC patients enrolled in the Italian Compassionate Use Program. A retrospective analysis was conducted in 29 Italian oncology centers among patients who completed at least one cycle of treatment. Data from 52 patients were gathered. Among them, 21.1% presented de novo stage IV; 78.8% previously received (neo)adjuvant treatment; 55.8% patients had only one site of metastasis; median number of treatment cycles was five (IQR: 3-8); objective response rate was 42.3% (95% CI: 28.9-55.7%). The median time-to-treatment discontinuation was 5 months (95% CI: 2.8-7.1); clinical benefit at 12 months was 45.8%. The median duration of response was 12.7 months (95% CI: 4.1-21.4). At a median follow-up of 20 months, the median progression-free survival was 6.3 months (95% CI: 3.9-8.7) and the median time to next treatment or death was 8.1 months (95% CI: 5.5-10.7). At 12 months and 24 months, the overall survival rates were 66.3% and 49.1%, respectively. The most common immune-related adverse events included rash (23.1%), hepatitis (11.5%), thyroiditis (11.5%) and pneumonia (9.6%). Within the ANASTASE study, patients with PD-L1-positive mTNBC treated with first-line atezolizumab plus nab-paclitaxel achieved PFS and ORR similar to those reported in the IMpassion130 study, with no unexpected adverse events.

Adjuvant capecitabine in triple negative breast cancer patients with residual disease after neoadjuvant treatment: real-world evidence from CaRe, a multicentric, observational study

Background

In triple negative breast cancer patients treated with neoadjuvant chemotherapy, residual disease at surgery is the most relevant unfavorable prognostic factor. Current guidelines consider the use of adjuvant capecitabine, based on the results of the randomized CREATE-X study, carried out in Asian patients and including a small subset of triple negative tumors. Thus far, evidence on Caucasian patients is limited, and no real-world data are available.

Methods

We carried out a multicenter, observational study, involving 44 oncologic centres. Triple negative breast cancer patients with residual disease, treated with adjuvant capecitabine from January 2017 through June 2021, were recruited. We primarily focused on treatment tolerability, with toxicity being reported as potential cause of treatment discontinuation. Secondarily, we assessed effectiveness in the overall study population and in a subset having a minimum follow-up of 2 years.

Results

Overall, 270 patients were retrospectively identified. The 50.4% of the patients had residual node positive disease, 7.8% and 81.9% had large or G3 residual tumor, respectively, and 80.4% a Ki-67 >20%. Toxicity-related treatment discontinuation was observed only in 10.4% of the patients. In the whole population, at a median follow-up of 15 months, 2-year disease-free survival was 62%, 2 and 3-year overall survival 84.0% and 76.2%, respectively. In 129 patients with a median follow-up of 25 months, 2-year disease-free survival was 43.4%, 2 and 3-year overall survival 78.0% and 70.8%, respectively. Six or more cycles of capecitabine were associated with more favourable outcomes compared with less than six cycles.

Conclusion

The CaRe study shows an unexpectedly good tolerance of adjuvant capecitabine in a real-world setting, although effectiveness appears to be lower than that observed in the CREATE-X study. Methodological differences between the two studies impose significant limits to comparability concerning effectiveness, and strongly invite further research.

PANHER study: a 20-year treatment outcome analysis from a multicentre observational study of HER2-positive advanced breast cancer patients from the real-world setting

Background:

The evolution of therapeutic landscape of human epidermal growth factor receptor-2 (HER2)-positive breast cancer (BC) has led to an unprecedented outcome improvement, even if the optimal sequence strategy is still debated. To address this issue and to provide a picture of the advancement of anti-HER2 treatments, we performed a large, multicenter, retrospective study of HER2-positive BC patients.

Methods:

The observational PANHER study included 1,328 HER2-positive advanced BC patients treated with HER2 blocking agents since June 2000 throughout July 2020. Endpoints of efficacy were progression-free survival (PFS) and overall survival (OS).

Results:

Patients who received a first-line pertuzumab-based regimen showed better PFS (p < 0.0001) and OS (p = 0.004) than those receiving other treatments. Median PFS and mOS from second-line starting were 8 and 28 months, without significant differences among various regimens. Pertuzumab-pretreated patients showed a mPFS and a mOS from second-line starting not significantly affected by type of second line, that is, T-DM1 or lapatinib/capecitabine (p = 0.80 and p = 0.45, respectively). Conversely, pertuzumab-naïve patients receiving second-line T-DM1 showed a significantly higher mPFS compared with that of patients treated with lapatinib/capecitabine (p = 0.004). Median OS from metastatic disease diagnosis was higher in patients treated with trastuzumab-based first line followed by second-line T-DM1 in comparison to pertuzumab-based first-line and second-line T-DM1 (p = 0.003), although these data might be partially influenced by more favorable prognostic characteristics of patients in the pre-pertuzumab era. No significant differences emerged when comparing patients treated with ‘old’ or ‘new’ drugs (p = 0.43), even though differences in the length of the follow-up between the two cohorts should be taken into account.

Conclusion:

Our results confirmed a relevant impact of first-line pertuzumab-based treatment and showed lower efficacy of second-line T-DM1 in trastuzumab/pertuzumab pretreated, as compared with pertuzumab-naïve patients. Our findings may help delineate a more appropriate therapeutic strategy in HER2-positive metastatic BC. Prospective randomized trials addressing this topic are awaited.

Eribulin Mesylate as Third or Subsequent Line Chemotherapy for Elderly Patients with Locally Recurrent or Metastatic Breast Cancer: A Multicentric Observational Study of GIOGer (Italian Group of Geriatric Oncology)-ERIBE

BACKGROUND

Metastatic breast cancer (MBC) is highly prevalent in middle-aged or elderly patients. Eribulin is a nontaxane microtubule inhibitor, approved for the treatment of pretreated MBC. This multicentric study (sponsored by GIOGer, Italian Group for Geriatric Oncology) was designed to assess the efficacy and tolerability of eribulin, according to parameters usually used in geriatric oncology.

SUBJECTS, MATERIALS, AND METHODS

An observational study was conducted on 50 consecutive elderly patients with MBC. The primary endpoint was to evaluate the change in items score of comprehensive geriatric assessment (CGA) and health-related quality of life (HRQL). Italian versions of the CGA and HRQL questionnaires were administered at baseline, before the third and fifth cycles, and then every three cycles until treatment discontinuation. Secondary endpoints were efficacy and safety.

RESULTS

Overall, both EQ-5D scores and EQ-5D-3 L visual analogic scale did not significantly change from baseline; the percentage of subjects without problems doing usual activities tended to decrease during treatment (p for linear trend .018), and the percentage of patients with minor problems performing usual activities tended to increase (p for linear trend.012). Among CGA items, Instrumental Activities of Daily Living tended to decrease during treatment and Geriatric Depression Scale tended to increase. After 12 months follow-up, 24 patients (out of 47) showed clinical benefits; median progression-free survival was 4.49 months (2.10-10.33) and median OS was 7.31 months (3.70-14.03). The treatment was associated with mild toxicity.

CONCLUSION

Eribulin treatment preserved quality of life and geriatric parameters included in the CGA, except for instrumental functioning and geriatric depression, in elderly patients with MBC.

IMPLICATIONS FOR PRACTICE

A collaboration between oncologist and geriatric specialists is essential in the management of patients with metastatic breast cancer, who are frequently elderly or frail. The assessment of geriatric parameters in the decision-making process can contribute to direct toward the most appropriate therapeutic plan and preserve the quality of life of patients. Eribulin does not seem to affect quality of life or worsen the overall geriatric status; therefore, it can be considered a suitable option for elderly patients with metastatic breast cancer.

Eribulin Treatment in Patients with Liver Metastatic Breast Cancer: Eight Italian Case Reports

Liver metastases are very common in metastatic breast cancer (MBC); current treatments for these lesions are based on systemic chemotherapy, endocrine- or human epidermal growth factor receptor 2 (HER2)-targeted therapy, and palliative therapy. However, no standard approach has been clearly identified for second and further chemotherapy lines in MBC patients. In the phase III clinical trial EMBRACE, eribulin was particularly effective in reducing liver lesions and improving both overall survival and progression-free survival in liver MBC patients. In this series, we collected 8 case reports of Italian clinical practice in which eribulin has shown significant efficacy in reducing liver metastases in MBC patients: complete response was reported in 2 patients, and 4 patients achieved partial response. The treatment was well tolerated, thus confirming that eribulin is a suitable therapeutic option for elderly patients and for those who have metastatic HER2-negative disease. In the setting of MBC, the sequencing of therapeutic agents should consider expected response, side effects, tumor characteristics, and patient's preferences, in order to successfully tailor the most appropriate therapy beyond earlier lines.

Incidence of Invasive Cervical Cancer and Direct Costs Associated with its Management in Italy

Aim and background

Cervical cancer is the second most common cancer in European women aged 15–44 years. The aim of this study was to estimate the direct cost of managing invasive cervical cancer in Italy.

Methods

Data from the Italian Network of Cancer Registries were used to estimate the annual number of new cervical cancer cases. To assess the management costs, a typical management pathway for each FIGO (Fédération Internationale de Gynécologie et d'Obstétrique) cervical cancer stage was derived from published guidelines. Data from the Modena Cancer Registry were used to estimate the proportion of patients by FIGO stage. This algorithm was combined with tariffs for outpatient and inpatient procedures to obtain a mean cost for each FIGO stage.

Results

An estimated 2,927 new cases of cervical cancer occurred in Italy in 2005 (crude incidence 9.7/100,000; world age-standardized incidence 6.0/100,000). The estimated numbers of new cases by FIGO stage were: FIGO I, 1,927; FIGO II, 556; FIGO III, 259; and FIGO IV, 185. Costs for the most frequent procedures were estimated as: € 6,041 for radical hysterectomy or other surgery; € 4,901 for radio-chemotherapy; € 1,588 for brachytherapy; and € 3,795 for palliative chemotherapy. Mean management costs for incident cases (including 10 years of follow-up) were estimated at: FIGO I, € 6,024; FIGO II, € 10,572; FIGO III, € 11,367; FIGO IV, € 8707; and € 5,854 for the terminal phase (1 month). The total direct management cost was estimated at € 28.3 million per year.

Conclusions

This is one of the first studies to estimate the direct cost of treating patients newly diagnosed with invasive cervical cancer in Italy. Although according to current management pathways real treatment costs are likely to be underestimated, this information is necessary to design evidence-based vaccination policies able to harmonize primary and secondary prevention of cervical cancer.

A new antioxidant formulation reduces the apoptotic and damaging effect of cigarette smoke extract on human bronchial epithelial cells

OBJECTIVE

In this study we evaluated the possible protective effect of an antioxidant formulation containing microfiltered milk derived polypeptides, Curcumin, Vitamin B2, Carnitine and N-Acetyl-cysteine (NAC) in an in vitro model of chronic obstructive pulmonary disease (COPD).

MATERIALS AND METHODS

Human bronchial epithelial cells (16HBE) were used in this study. Cells were treated for 24 h in the presence or absence of 10% of cigarette smoke extract (CSE) and in the presence or absence of antioxidant formulation. We evaluated cell viability by MTT assay, reactive oxygen species by flow cytometer and quantitative analysis of gene expression by Real-time PCR.

RESULTS

The data obtained showed a significant increase of cell viability in CSE-exposed cells and a significant reduction of reactive oxygen species (ROS) production compared to cells treated with only CSE. The antioxidant effects of formulation were confirmed by a decrease of inflammatory cytokines genes IL-1β, IL-6, TNFα, nitric oxide synthase gene (NOS2) and through an induction of antioxidant genes such as heme oxygenase 1 (HO-1), nuclear transcription factor erythroid 2 (NRF2) and peroxisome proliferator-activated receptor gamma coactivator-1 alpha (PGC-1α).

CONCLUSIONS

The results suggest that antioxidants combination plays a protective role on oxidative stress and inflammation, in an in vitro model of COPD, activating key genes in response to oxidative stress and decreasing the cytokines responsible for the inflammatory pathways.

FOLFOX-4 Regimen as First-Line Chemotherapy in Elderly Patients with Advanced Gastric Cancer: A Safety Study

Gastric cancer is often diagnosed in advanced stage (AGC) and in elderly patients. Current chemotherapies induce severe toxicity and are difficult to deliver. Some authors have shown the activity and safety of oxaliplatin with various 5-fluorouracil (FU) and leucovorin (LV) infusions in AGC. The aim of our study was to evaluate the feasibility of the FOLFOX-4 regimen in elderly patients with AGC. From 6/2003 to 7/2005, 33 patients (median age 74 years, range 66-79 years) were enrolled into the study. 31 patients were assessable for the safety analysis and for response. We recorded complete response in 4 patients (13%), partial response in 6 patients (19%), 9 (29%) stable disease and 12 progressive disease for an overall response rate of 32% (95% CI, 16% to 48%). At median follow-up of 20 months the median time to progression was 6.4 months. The therapy was well tolerated, the main G1/2 toxicities were nausea, vomiting and diarrhea. Only 2 patients suffered from severe vomiting. Severe hematologic toxicities were uncommon. Anemia G3 was recorded in 3 patients, neutropenia G3 in 6 patients and febrile neutropenia in 1 patient. G1 and G2 neurotoxicity were a common event while G3 sensorial neuropathy was not reported. We conclude that although our patients were elderly and most had a PS 2, the regimen was manageable, easy to deliver, well accepted by the patients and active.

Carboplatin and gemcitabine combination in metastatic triple-negative anthracycline- and taxane-pretreated breast cancer patients: a phase II study

Triple-negative breast cancer (TNBC) is characterized by lack of hormone receptors and HER-2 and shares many features with BRCA1-associated cancer. Preclinical data indicate cisplatin sensitivity, suggesting that these tumors may have defects in the BRCA1 pathway. The carboplatin and gemcitabine (CG) combination is active in unselected anthracycline/taxane pretreated metastatic breast cancer patients, so we carried out a phase II study to evaluate the activity of the CG combination in pretreated metastatic TNBC patients. From 10/2004 to 3/2009 we enrolled 31 patients. Median age was 57 years and 29 patients out of 31 had visceral involvement. The overall response rate (ORR) was 32% (1 complete response /9 partial responses), in addition 5 patients obtained stable disease for >12 weeks. After a median follow-up of 34 months, all patients progressed with a median time to progression of 5.5 months and median overall survival of 11 months. Dose reductions, delays and omissions occurred in 75 (60%), 36 (29%) and 22 (18%) cycles. Grade 3/4 neutropenia occurred in 17 and febrile neutropenia in 4 patients. Ten patients had Grade 3/4 thrombocytopenia. Non hematological toxicities were manageable. The CG combination is a reasonable option for the treatment of metastatic pretreated TNBC patients.

Incidence of arthralgia syndrome (AS) related to aromatase inhibitors (AIs) in postmenopausal women with early breast cancer (EBC)

e11603

Background: Anastozole (A) and letrozole (L) are standard drugs in up-front adjuvant endocrine therapy in postmenopausal hormone positive EBC. AIs have a higher incidence of osteoporosis, bone fractures and musculoskeletal symptoms, particularly joint pain and stiffness (AS) respect to tamoxifen. The real incidence of AS can be underestimated respect to data derived from clinical trials. Methods: From 1/07 to 12/07 we registered all patients (pts) taking A or L as adjuvant therapy for at least 3 months. We screened 47 pts, 3 pts refused to participate at the study and 2 resulted metastatic. A total of 42 pts were enrolled. The median age was 67 yrs (range 51–89), the median time since menopause was 11 yrs (range 1–48). 30 pts had natural menopause, 7 surgical menopause and 5 reported chemo-induced menopause. 25 pts took A and 17 pts took L. The median duration on therapy was 19 months (range 3–68) and 31 pts had received chemotherapy (9 CMF, 17 anthra-based, 5 anthra-taxane based). Results: 11 pts (26%) did not report AS, 19 pts (45%) had new-onset AS and 12 (29%) had worsening of prior joint pain after starting adjuvant AIs therapy. Most pts reported moderate to severe AS requiring occasional use of nonsteroidal anti-inflammatory drugs (75%), 15% used oral supplements and 10% used opiates, only 4 women used exercise to relieve joint stiffness. 17 pts interrupted the therapy from 7 to 20 days in order to reduce the symptoms and 7 obtained a partial improvement. 11 pts (35%) suffered from AS declared the worsening of quality of life. In univariate analysis presence of AS was not associated with age, entry into menopause, years since menopause, duration of AI therapy or previous chemotherapy. Conclusions: Our data show a higher incidence of AS in clinical practice respect to literature data, which caused worsening of quality of life and could be reason of discontinuation of effective therapy. The exact mechanism of AIs-related arthralgia is unclear, but is believed to be related to estrogen deprivation, however further studies are needed to define the pathogenesis in order to find an effective therapy.

No significant financial relationships to disclose.

Metronomic irinotecan and standard FOLFIRI regimen as first-line chemotherapy in metastatic colorectal cancer (MCRC). Final results of phase II study

14520

Background: Angiogenesis is necessary to sustain the growth of both the primary tumour and the development of metastases in colorectal cancer. Before the clinical use of bevacizumab, metronomic chemotherapy was the only mean to block the growth of tumor microvessel. CPT-11 showed, in preclinical model, to have antiangiogenetic properties using low doses and weekly administration. We carried out this study in order to evaluate the activity and toxicity of mixed metronomic and standard FOLFIRI regimen in MCRC. Methods: From 10/03 to 9/05 we treated 46 pts (24M 22F), median age 66 years (range 41–79), ECOG PS 0–2 with this schedule: CPT- 11 10 mg/mq days 1, 7, 10 and CPT-11 150 mg/mq day 2, l-Folinic Acid 100 mg/mq days 2 and 3, 5-FU 400 mg/mq bolus days 2 and 3 and 5- FU 600 mg/mq 44 hours c.i. days 2 and 3 every two weeks for a maximum of 12 cycles. Results: All pts have been evaluable activity and toxicity. We obtained 9 CR (20%), 12 PR (26%) with an ORR of 46% (CI 95%: ±13%) and 17 SD. After a median follow-up of 24 months we registered a median TTP of 10 months and a median OS of 22 months. As regard toxicity, the chemotherapy has been well tolerated; no toxic deaths occurred and no therapy ended for toxicity. 6 pts had 25% dose reduction (standard schedule) for diarrhea G4 after the first cycle. The main toxicities recorded on a total of 440 cycles (cy) delivered were: diarrhea G4 1.7% and G3 2.3% of the cy. Neutropenia G3 5.8% and vomiting G3 0.5% of the cy. Anemia G2 was recorded in 14 pts. All pts suffered from partial alopecia and half of the pts from mild oral mucositis. Conclusions: This mixed schedule seems to be active and well tolerated, ORR, TTP and OS are similar to Hurwitz results (NEJM 2004; 350: 2335–42) but with less adverse events. The combination of this schedule with bevacizumab deserves further studies.

No significant financial relationships to disclose.

First line chemotherapy with FOLFOX 4 in elderly patients (>65 years) with advanced or metastatic gastric cancer (A/MGC): A pilot study

14095

Background: Cisplatin/5-FU based regimens are considered therapies of choice for the treatment of A/MGC even if severe toxicities are reported especially in elderly pts. FOLFOX 4 regimen is standard chemotherapy in adjuvant and metastatic colorectal cancer and it is effective and well tolerated also in elderly population. Several trials have showed activity and safety of FOLFOX regimen in A/MGC. For these reasons, we carried out this pilot study in order to evaluate the feasibility of FOLFOX 4 in elderly pts (>65 yrs) with A/MGC. Methods: From June 2003 to June 2005 we treated with FOLFOX 4 regimen 31 pts with median age of 70 yrs (range 66–79), 20 males and 11 females, ECOG PS 0–2 with MGC in 19 cases and AGC in 12 cases. All pts had measurable disease according to RECIST criteria, NCI-CTC was employed to grade toxicity except for neurotoxicity graded by specific scale. Results: We recorded 4 CR (13%), 6 PR (19%), 9 SD (29%) and 12 PD for an ORR 32% and median TTP of 6.8 months. A total of 281 courses were delivered with a median of 8 courses (range 4–15) per pt. No toxic deaths occurred and no therapy has been ended for toxicity or pt refusal. Pts did not receive G-CSF support. 43 courses were delayed for toxicity (maximum 2 weeks). Haematological adverse events were: 23 episodes of neutropenia G1/2, 8 episodes of G3 and 3 episodes of G4 neutropenia; G1/2 thrombocytopenia occurred in 15 episodes; anemia G1/2 was reported in 13 episodes. Besides, we recorded 12 episodes of emesis G2 and 2 episodes of G3; 24 episodes of G1/2 and 7 episodes of G3 oral mucositis were recorded; diarrhoea G1/2 was a common event (around 50% of cycles) while severe diarrhoea was a rare. Alopecia G1/2 was registered in 19 pts, G1neurosensorial toxicity (specific scale) occurred in 16 pts, G2 in 7 pts and G3 in one pt. One pt had hypersensitivity reaction at first infusion that did not occurred anyone by prolonged infusion of L-OHP. Conclusions: Our data show that FOLFOX 4 is active in the treatment of A/MGC and that toxicity profile is favourable in elderly population in comparison to standard regimens.

No significant financial relationships to disclose.

Retrospective analysis of adverse drug reactions induced by gemcitabine treatment in patients with non-small cell lung cancer

Non-small cell lung cancer (NSCLC) is the leading cause of cancer death in the world. Traditional chemotherapy for advanced NSCLC is often considered excessively toxic. Recent clinical trials documented that gemcitabine may represent a good therapeutical option in patients with NSCLC. Aim of our research was to retrospectively evaluate the adverse effects induced by gemcitabine in patients with NSCLC from 1 January 1997 to 31 December 2002, in clinical records of Oncology Divisions of "S. Giovanni di Dio" Hospital of Crotone, "Ospedali Riuniti" Hospital of Reggio Calabria, Hospital of Paola, and in Pneumological Oncology Division of "Mariano Santo" Hospital of Cosenza, Italy. Clinical records of patients treated with gemcitabine (1000mgm(-2) on days 1 and 8) were reviewed and following data were obtained: sex and age of the patients, histologic diagnosis and disease stage, World Health Organisation (WHO) performance status and toxic effects induced by gemcitabine. We reported that 71.6% of NSCLC patients (age range 48-77 years; 135 males, 27 females; performance status 0=53, 1=109) were eligible for our study. Side effect of gemcitabine involved gastrointestinal system (nausea, vomiting and diarrhoea) and only in the last cycles (VIII-XI) emopoiethic system (leukopenia, neutropenia, thrombocytopenia and anemia). Grade IV vomiting occurred in three patients, thrombocytopenia in two. Grade III leukopenia was observed in three patients. Other toxicities were mild. None of the patients died during chemotherapy. In conclusion, these data showed that gemcitabine present a very good tolerability in patients with NSCLC. Therefore, it could be considered as a new therapeutic agents to use as first line therapy for this disease.

5-Fluorouracil plus Folinic Acid with or without Ifosfamide in Advanced Colorectal Cancer: A Phase II Randomized Trial

Aim

This phase II trial evaluated the biomodulation of 5-fluorouracil (5-FU) plus folinic acid (FA) with or without ifosfamide (IFO) in chemotherapy-naive patients with colorectal cancer.

Patients and methods

Forty-eight patients were randomized to receive: FA (25 mg/m2 iv bolus days 1 to 3), followed by 5-FU (750 mg/m2 iv bolus days 1 to 3), arm A; or FA (25 mg/m2 iv bolus days 1 to 3), followed by 5-FU (750 mg/m2 iv bolus days 1 to 3) plus IFO (2,000 mg/m2 in 1000 mL 5% dextrose in a 2-hr infusion, days 1 to 3), arm B. Mesna was added during and after IFO to prevent hemorrhagic cystitis. Treatment was repeated every 21 days in both arms.

Results

Forty-five patients were assessable for response: in arm A, 5 patients achieved a partial response (overall response, 25%), and in arm B, 2 patients achieved a complete and 1 a partial response (overall response, 12%). Time to failure was 3.5 months (range, 1–38) in patients treated with 5-FU plus FA, and 3 months (range, 1–21) in patients treated with the IFO combination. The median survival time was 13.5 months (range, 1–49 months) in arm A and 16 months (range, 1–43 months) in arm B. Diarrhea, stomatitis and vomiting were the most common nonhematologic toxicities in both arms. The most notable hematologic toxicity was leukopenia; 15% and 20% of patients experienced grade 4 in arm A and arm B, respectively.

Conclusions

IFO does not increase the activity of the 5-FU plus FA combination in advanced colorectal cancer.

Angiosuppression and chemotherapy: strategies aimed at their integration in cancer patients

A number of antiangiogenic agents have been developed as pharmaceuticals and are currently being tested in clinical studies. Potential strategies to enhance the activity of angiogenesis inhibitors could be to combine them, or better still, to administer them either sequentially or concurrently with cytotoxic drugs. Chemotherapy would be a more appropriate initial choice for patients with advanced disease since cytostatic agents can induce a fast regression of the tumor and cancer-related symptoms. Antiangiogenic treatment could be used after chemotherapy in patients who achieve disease remission to prolong the time to progression, the symptom-free interval and the overall survival. Antiangiogenic treatment is likely to attain an important role in the adjuvant setting. In fact, it could be used for prolonged periods after radical surgery to maintain dormancy of residual tumor cells. In spite of these promising preclinical data, several points need to be clarified before the initiation of clinical trials. In fact, certain misconceptions may interfere with their optimum design and result analysis.

Does subarachnoid blood extravasation per se induce long-term neuropsychological and cognitive alterations?

Although recent advances in medical and management strategies have reduced the mortality and morbidity rates related to subarachnoid haemorrhage (SAH), patients who survive a SAH may remain nevertheless affected by persistent cognitive and neuropsychological disturbances. The presence of these deficits has been attributed to the neurotoxic effects of the widespread subarachnoid blood. To assess the long-term neuropsychological and cognitive outcome related to subarachnoid blood extravasation per se we evaluated 20 patients affected by an unknown origin subarachnoid haemorrhage, and having SAH characteristics generally considered predictive of a favourable outcome. Patients were enrolled after a one-year interval from the initial insult, and were selected accordingly to a pre-designed protocol. We employed a complete battery of tests, assessing general cognitive and language functions, memory and construction ability, attention and vigilance, anxiety and depression. The results were compared with normal reference values and with performances of a socio-demographically homogenous sample of control volunteers. This study did not evidence any significant long-term cognitive and neuropsychological alteration after subarachnoid blood extravasation. These results indicate that the presence of subarachnoid blood initiate a number of secondary mechanisms of pathology.

Onset of hepatocellular carcinoma in a non-cirrhotic patient affected with haemochromatosis

The increased incidence of hepatocellular carcinoma in patients affected with haemochromatosis has previously been attributed to cirrhosis. However, some cases of hepatocellular carcinoma without cirrhosis have recently been reported in patients with haemochromatosis, leading to reconsideration of the role of iron in the tumorigenesis of hepatocellular carcinoma. We describe a 79 year old male patient affected with haemochromatosis and with a multinodular hepatocellular carcinoma, but without any evidence of cirrhosis. The absence of any other cancer risk factor (alcohol abuse, liver viral infections, heredity) has lead us to reconsider the possible role of iron as a direct carcinogen in the onset of hepatocellular carcinoma in patients with haemochromatosis.

Is there a group of early surgery aneurysmal SAH patients who can expect to achieve a complete long-term neuropsychological recovery?

There is a significant controversy regarding the effect of early surgical intervention for microsurgical aneurysm clipping on long-term cognitive recovery. Although new strategies in surgical and medical management have progressively reduced the morbidity and mortality rates related to subarachnoid haemorrhage (SAH), the overall quality of life of aneurysm patients has been reported to remain unsatisfactory. In fact, even in the presence of a good neurological recovery following an aneurysmal SAH, patients may show persistent emotional and psychological disturbances. The aim of this study was to analyse the long-term cognitive, neuropsychological and emotional status of a group of patients, subjected to early surgery aneurysm treatment, and having SAH characteristics generally considered predictive of a favourable outcome. Patients were submitted to a complete battery of neuropsychological tests designed to assess a full range of cognitive and attentional functions. The results of the neuropsychological evaluation did not detect evidence of any significant cognitive deterioration as compared to control volunteers and to the published age-adjusted test norms. These results indicate that early aneurysm surgery, coupled with modern microneurosurgical techniques and aggressive medical management is associated with a good neurological outcome and a full recovery of cognitive, neuropsychological and emotional performances in a subset of patients with favourable clinical characteristics.

[Interferons in the therapy of solid tumors]

Belonging to the vast family of cytokines, interferons (IFN) have recently been widely investigated concerning their possible clinical applications, both in virology and oncology. In this field results have been quite mixed but definitely encouraging. The best achievements have been obtained in hematology, and particularly in the treatment of hairy cell leukemia and chronic myelogenous leukemia, but new perspectives have also opened in the therapy of solid tumors, especially in the local treatment of superficial bladder cancer and ovarian cancer, AIDS-related Kaposi's sarcoma and malignant melanoma. IFN have in certain cases showed an efficacy comparable to that of classic treatments but with lower toxicity, and in some tumors they have even improved the results obtained so far, especially in combined therapy. We have here gathered the most recent results concerning the use of IFN in the therapy of solid tumors in order to highlight the new therapeutic opportunities available to clinical oncology.

Sleep features in Tourette's syndrome, neuroacanthocytosis and Huntington's chorea

Twenty-one patients affected by extrapyramidal disorders were polygraphically recorded during spontaneous nocturnal sleep for two consecutive nights to assess their sleep and movement patterns. The patients (pts) sample included: Gilles de La Tourette syndrome (TS, nine pts), neuroacanthocytosis (NA, six pts) and Hungtington's chorea (HC, six pts). Sleep recording included C3/A2, 01/A2, ROC/LOC, submental EMG, EKG, nasal airflow thoracoabdominal respirogram, bilateral anterior tibialis and other EMGs, in relation to the individual distribution of the abnormal movements. According to our observations, abnormal movements always decreased but never ceased completely during sleep. Sleep efficiency (SE) was nearly always poor with a high percentage of wakefulness after sleep onset (WASO) and increased number of arousals. REM sleep was often reduced and in some cases (3 TS pts) incompletely defined as far as its microstructural aspects. Slow wave sleep (SWS) was reduced in HC, normal in NA, and increased in all TS patients with the exception of the two adult subjects more severely affected, while the percentage of stage 2 was not affected. Spindling was increased in NA, HC and in the two most severely affected adult TS patients.

Serotoninergic agents in the treatment of Gilles de la Tourette's syndrome

A preliminary trial with fluoxetine, a 5-HT reuptake inhibitor, was carried out on two young male patients (21 and 32 years old) affected by Gilles de la Tourette syndrome. They both underwent a complete neurological evaluation also including neuroradiological, neurophysiological and neuropsychological assessment. Both patients had already been treated with benzodiazepines and amitriptyline; the older one was also given haloperidol and chlorimipramine with definite, but short-lasting improvement. During hospitalization a therapeutic trial with fluoxetine (20 mg/day in the younger patient and 40 mg/day in the older) in association with chlorimipramine (75 mg/day) was initiated, leading to a significant reduction (at least 50%) of abnormal movements and obsessive-compulsive behaviour. The older patient had no side effects while the 21 year old subject complained of insomnia, urinary retention and anorexia; despite the objective improvement, these side effects led us to modify the therapy after the first month. The favourable action of serotoninergic agents on TS symptoms supports the hypothesis that the multiple tics of the syndrome are motor compulsions.

Indole-3-pyruvic acid as a possible hypnotic agent in insomniac subjects

In a single-blind study six male patients (mean age 39.5 years) with moderate insomnia were treated with placebo for three nights, 100 mg indole-3-pyruvic acid (IPA) for three nights, 200 mg IPA for three nights, 100 mg IPA for two nights and placebo for two nights. Polygraphic recordings were made and total sleep time, sleep efficiency, sleep latency, slow wave sleep latency, rapid eye movement (REM) sleep latency, number of arousals (greater than 1 min), percentage and duration of wakefulness after sleep onset, percentage and duration of wakefulness after sleep onset, percentage and duration of sleep stages 1, 2, 3, 4 and REM were recorded. At the end of 13 days, total sleep time, duration of stage 2 sleep and total non-REM were significantly increased when compared with baseline. Total sleep time and duration of stage 2 and total non-REM sleep on completion were significantly decreased when compared with after 200 mg IPA (night 9). Results suggest an action of IPA on human sleep similar to that of exogenous melatonin and L-tryptophan, thus confirming that IPA could be used to increase serotonin and melatonin turnover.

[Gilles de la Tourette disease: review of the literature]

The authors reviewed recent literature reports on Gilles de la Tourette syndrome. Clinical aspects, etiopathogenetic theories and therapeutic trials were taken into account, to better define the disease and its rational therapeutic approach.

Narcolepsy and psychopathology. A case report

The case of a 14-year-old girl presenting with the association of a clearcut narcoleptic syndrome and psychiatric disturbances is reported. Tricyclic anti-depressant drugs and hypnagogic hallucinations seem to play a precipitating role on delusional episodes in a predisposed subject with a positive psychiatric familial history.

[Pelvic carcinomatous neuropathy: clinical, radiologic, therapeutic implications]

Carcinomatous involvement of the pelvic nerves (Pelvic Carcinomatous Neuropathy-PCN-) causes disabling sensorial and motor disturbances of the lower extremities. Recurrent rectal carcinomas are the most common cause of PCN because surgical obliteration of the perirectal fascia. In 31 cases of PCN Authors describe the types of the neoplasm and the sites of involvement of the pelvic nerves evaluating clinical syndromes and Computed Tomography. The results of radiotherapy (doses between 36-56 Gy) in 14 cases of PCN by recurrent rectal cancer are also reported. Although the survival of such patients is poor, radiotherapy has obtained a good palliative result in 50% of them. Personalization of radiation treatment planning is advisable in order to avoid acute side-effects.

Vascular compression from goiter as an unusual cause of cerebrovascular accident

The unusual case of a patient with goiter and left faciobrachiocrural paresis due to right temporoparietal infarction is reported. Cerebral angioscintigram and arteriography showed a brachiocephalic and right subclavian stenosis secondary to compression by an extended thyroid nodule.

Wakefulness and sleep autonomic dysfunction in diabetics

Parasympathetic and sympathetic controls on cardiovascular systems were studied during wakefulness and sleep in 8 diabetic patients (3 IDDM and 5 NIDDM), in order to detect the presence of autonomic dysfunction. In particular, cardiovascular assessment during sleep allowed to detect minimal autonomic abnormalities in the absence of a documented pathology during wakefulness.

Hypnogenic paroxysmal dystonia: a new type of parasomnia?

Four cases of hypnogenic paroxysmal dystonia are described. The patients (three males and one female), aged between 12 and 39 were subjected to neurological, physical and psychological examination, and routine lab tests and brain CT scan were carried out within normal limits. One of the patients suffered from diurnal epileptic seizures. Repeated EEG recordings during wakefulness were normal. During polysomnographic and TV recordings the patients showed different types of dystonic fits occurring several times a night, always brief, and starting during NREM sleep. Carbamazepine therapy proved to be relatively effective in three subjects.