Late effects in survivors of high-risk neuroblastoma following stem cell transplant with and without total body irradiation

BACKGROUND

Neuroblastoma is the most common extracranial solid tumor in children. Those with high-risk disease are treated with multimodal therapy, including high-dose chemotherapy, stem cell transplant, radiation, and immunotherapy that have led to multiple long-term complications in survivors. In the late 1990s, consolidation therapy involved myeloablative conditioning including total body irradiation (TBI) with autologous stem cell rescue. Recognizing the significant long-term toxicities of exposure to TBI, more contemporary treatment protocols have removed this from conditioning regimens. This study examines an expanded cohort of 48 high-risk neuroblastoma patients to identify differences in the late effect profiles for those treated with TBI and those treated without TBI.

PROCEDURE

Data on the study cohort were collected from clinic charts, provider documentation in the electronic medical record of visits to survivorship clinic, including all subspecialists, and ancillary reports of laboratory and diagnostic tests done as part of risk-based screening at each visit.

RESULTS

All 48 survivors of BMT for high-risk neuroblastoma had numerous late effects of therapy, with 73% having between five and 10 late effects. TBI impacted some late effects significantly, including growth hormone deficiency (GHD), bone outcomes, and cataracts.

CONCLUSION

Although high-risk neuroblastoma survivors treated with TBI have significant late effects, those treated without TBI also continue to have significant morbidity related to high-dose chemotherapy and local radiation. A multidisciplinary care team assists in providing comprehensive care to those survivors who are at highest risk for significant late effects.

When Reality and Research Collide: Guidelines Are Essential for Optimal Nutrition Care in Pediatric Oncology

Nutritional problems are common in pediatric oncology due to the side effects of the disease and treatment. Nutrition intervention can be challenging, and little is known about the current clinical practice of registered dietitian nutritionists. An online questionnaire emailed to members of the pediatric, oncology nutrition, and clinical manager practice groups of the Academy of Nutrition and Dietetics, consisted of items related to current nutrition practice. Our questionnaire results suggest that the field of pediatric oncology is employed with relatively new dietitians (62% had <5 y of experience). Many registered dietitian nutritionists (60%) are providing care across the cancer care continuum (standard therapy, transplant, and survivorship) versus specializing in a particular area. Approximately half (52%) felt that their center had inadequate staffing, many reporting little in the outpatient setting. Barriers to providing optimal patient care included inadequate staffing, lack of time for research initiatives, and lack of evidence-based guidelines. Future studies should determine follow-up guidelines and appropriate staffing ratios for nutrition care in pediatric oncology. Approaches should be developed to support less experienced dietitians. Collaboration between dietitians at different facilities will likely be key in developing essential evidence-informed guidelines.

P3342Prevalence of patients with paroxysmal supraventricular tachycardia (PSVT) in the United States

Background/Introduction

PSVT is a sporadic, sudden and recurring tachycardia that can be difficult to diagnose. Estimates based on an initial healthcare encounter may underestimate PSVT prevalence because patients may have multiple encounters before definitive diagnosis.

Purpose

To estimate the prevalence of PSVT patients in the US using longitudinal data.

Methods

Retrospective study that used demographic, enrollment and claims data from Truven MarketScan® (age <65y) and Medicare Limited Dataset (age≥65y) databases from 2008–2016. All individuals continuously enrolled in their health plans for 5 years were included; PSVT patients were required to have claims with a PSVT diagnosis (ICD-9: 427.0; ICD-10: I47.1) on 2+ outpatient visits, 1+ inpatient admission or 1+ ED visit. The 9-year period prevalence was calculated as the number of PSVT patients /number of individuals observable for 5 continuous years, and the 9-year prevalence from the study population was projected to the U.S. population by sex and age (<18, 18–34, 35–44, 45–54, 55–64, ≥65) using 2010–2016 U.S. census data.

Results

Of 18,057,297 study patients, 86,630 met criteria for PSVT. Projected to the US population, prevalence estimates ranged from 1,749,358 in 2010 to 1,967,532 in 2016. Prevalence rates increased with age, from 0.871/1,000 (<18y) to 5.031/1,000 (45–54y) and 21.881/1,000 (≥65y). Prevalence rates were higher for females in all age groups, except the <18y cohort, but the difference in prevalence between female and male patients decreased with age. Relative rates of PSVT were more than twice as high for females age 18–44y, while prevalence rates were 1.3 to 1.6 times higher in females age 45y and above (Table).

Prevalence of PSVT in the US by Age and Gender, 2010–2016 Age Prevalence/1,000 [Female; Male] US Population (Year) Projected Prevalence (US) <18 0.871 [0.898; 0.845] 323,127,513 (2016) 1,967,532 18–34 2.268 [3.023; 1.440] 320,896,618 (2015) 1,930,746 35–44 3.313 [4,340; 2.147] 318,563,456 (2014) 1,892,923 45–54 5.031 [6.058; 3.845] 316,204,908 (2013) 1,855,256 55–64 7.761 [8.663; 6.727] 313,998,379 (2012) 1,818,690 65+ 21.881 [24.480; 18.329] 311,663,358 (2011) 1,777,397 Total 4.798 [5.823; 3.668] 309,348,193 (2010) 1,749,064

Conclusions

Based on insurance claims data, PSVT affected 1.7–2 million individuals in the U.S. annually between 2010 and 2016. Prevalence rates were higher in older individuals and females, with much higher rates for females ages 18–44y relative to males. Estimates that rely on a single medical encounter may underestimate PSVT prevalence.

A Multidisciplinary Review of Nutrition Considerations in the Pediatric Oncology Population: A Perspective From Children's Oncology Group

Over the past few decades, great progress has been made in the survival rates of childhood cancer. As survival rates have improved, there has been an increased focus on supportive care. Nutrition is a supportive-care modality that has been associated with improved tolerance to chemotherapy, improved survival, increased quality of life, and decreased risk of infection in children undergoing anticancer therapy. Guidelines and assessment criteria have been proposed for the nutrition management of a child with cancer; however, there is no consistent use of criteria among institutions treating children with cancer. This review will present the current evidence and standards of practice incorporating aspects of nutrition, nursing, pharmacology, and psychosocial challenges to consider in the nutrition management of a child with cancer. Recommendations for clinical practice are presented.

Proactive enteral tube feeding in pediatric patients undergoing chemotherapy

BACKGROUND

To determine feasibility and safety of proactive enteral tube feeding (ETF) in pediatric oncology patients.

METHODS

Pediatric patients with newly diagnosed brain tumors, myeloid leukemia or high-risk solid tumors were eligible. Subjects agreeing to start ETF before cycle 2 chemotherapy were considered proactive participants (PPs). Those who declined could enroll as chart collection receiving nutritional standard of care. Nutritional status was assessed using standard anthropometric measurements. Episodes of infection and toxicity related to ETF were documented from diagnosis to end of therapy. A descriptive comparison between PPs and controls was conducted.

RESULTS

One hundred four eligible patients were identified; 69 enrolled (20 PPs and 49 controls). At diagnosis, 17% of all subjects were underweight and 26% overweight. Barriers to enrollment included physician, subject and/or family refusal, and inability to initiate ETF prior to cycle 2 of chemotherapy. Toxicity of ETF was minimal, but higher percentage of subjects in the proactive group had episodes of infection than controls. Thirty-nine percent of controls eventually started ETF and were twice as likely to receive parenteral nutrition. PPs experienced less weight loss at ETF initiation than controls receiving ETF and were the only group to demonstrate improved nutritional status at end of study.

CONCLUSIONS

Proactive ETF is feasible in children with cancer and results in improved nutritional status at end of therapy. Episodes of infection in this study are concerning; therefore, a larger randomized trial is required to further delineate infectious risks and toxicities that may be mitigated by improved nutritional status.

Weight patterns in children with higher risk ALL: A report from the Children's Oncology Group (COG) for CCG 1961

BACKGROUND

This retrospective analysis defined and described patterns and predictors of weight change during treatment in children with acute lymphocytic leukemia (ALL) with high-risk features who received treatment on Children's Cancer Group protocol CCG 1961.

PROCEDURE

Patients (1,638) were enrolled in CCG 1961 from November 1996 to May 2002. Weight was measured as BMI percent (%), specific for age and gender, and defined as 100 x ln(BMI/median BMI).

RESULTS

By the end of treatment, 23% of children were obese (BMI >or=95%), compared with 14% at diagnosis. Children who received post-induction intensified therapy (arms C, D, SER with Doxorubicin or Idarubicin) had higher gastrointestinal toxicities and lower BMI% from consolidation through interim maintenance 1. BMI% then increased for all arms between delayed intensification and maintenance 1 or 2. Children who were of Black or Hispanic race, obese at diagnosis, or who had grade 3 or 4 pancreatitis/glucose toxicities during induction had higher BMI% throughout treatment. Children were more likely to be obese at the end of the study if they were aged 5-9 years at diagnosis or female gender. Cranial radiation was not a predictor of obesity.

CONCLUSIONS

Successful treatment of higher risk childhood ALL was associated with obesity, independent of cranial irradiation. The beginning of maintenance therapy may be the best time to intervene with nutritional and behavioral interventions, particularly for children who are obese or aged 5-9 years at diagnosis, female, Black or Hispanic, or those with metabolic toxicities during induction.

Late effects in survivors of tandem peripheral blood stem cell transplant for high-risk neuroblastoma

BACKGROUND

Increasing numbers of children with advanced neuroblastoma are achieving cure. We describe the clinical late effects specific to survivors of stage IV neuroblastoma all similarly treated using tandem autologous peripheral blood stem cell rescue with TBI.

METHOD

The medical records of 35 neuroblastoma patients treated at CHOP between 1997 and 2001 were examined. Eighteen of the 35 patients died of progressive disease, and 4 were lost to follow-up. Thirteen patients continue to follow-up in our Multidisciplinary Cancer Survivorship Clinic where they are evaluated and monitored by a consistent group of subspecialists that evaluate long-term sequelae. Data on treatment exposures including TBI and treatment related sequelae identified by clinician assessment and/or diagnostic testing were collected.

RESULTS

Results indicate late effects were present in all 13 subjects, 12 of whom suffered from multiple negative sequelae, including issues with growth hormone deficiency, dental problems, osteochondromas and hearing deficiencies, among others, most at higher rates than reported previously.

CONCLUSIONS

The findings in this small cohort indicate the need for future prospective studies of this intensive pediatric cancer treatment, and underscore the importance of medical intervention and long-term monitoring of these at-risk subjects to increase overall quality-of-life.

Children's Oncology Group (COG) Nutrition Committee

The Children's Oncology Group (COG) Nutrition Committee was established to further the knowledge of nutrition in children with cancer by education and the conduct of clinical trials. A survey of COG institutions revealed lack of conformity in evaluation and categorization of nutritional status, and criteria for nutritional intervention. The Committee subsequently established specific categories of malnutrition (Underweight and Overweight) based on ideal body weight or body mass index. An algorithm was developed as a guideline for nutritional intervention as well as references and resources for determining estimated needs. The Committee embarked on concepts for clinical trials of nutritional interventions. The first pilot study, evaluating the feasibility of using an immunoneutraceutical precursor for glutathione production, has been completed. This study showed weight gain and improvement in glutathione status. A pilot trial of proactive enteral feeding for patients at high risk of malnutrition has commenced. The Committee believes that nutrition is relevant to all aspects of cancer control. The paucity of nutritional investigation in children with cancer needs to be rectified.

Biochemical and immunologic correlates of clinical response in a combination trial of the GM-CSF-gene transduced allogeneic prostate cancer immunotherapy and ipilimumab in patients with metastatic hormone-refractory prostate cancer (mHRPC)

5120

Background: A Phase 1 trial is underway to study the GM-CSF-secreting immunotherapy for prostate cancer (GVAX immunotherapy [GVAX IT]) and ipilimumab (ipi) in mHRPC patients (pts). Methods: Twelve pts were treated for 24 weeks (wks) with bi-weekly intradermal injections of GVAX IT and monthly Ipi. Pts were enrolled in cohorts of 3; each cohort received an escalating dose of ipi: 0.3, 1, 3 or 5 mg/kg. Results: Median follow-up is 15.0 months. All pts had GVAX IT injection site reactions. Five of six pts at the higher ipi doses (3 and 5 mg/kg) developed Grade 2 or 3 immune-related endocrinopathy, consistent with hypophysitis manifested by adrenal insufficiency and/or hypothyroidism, all successfully treated with standard hormone replacement. Two pts were tapered off Synthroid within 6 months (m). There was no induction of the alpha-21-hydroxylase auto-antibody that is seen in 90% of cases of auto-immune adrenal insufficiency. One pt in the 5 mg group developed a Grade 3 dose-limiting alveolitis. PSA responses (declines > 50%) were seen in 5/6 treated at the two higher ipi doses with median response duration of 4.9 m (2 on-going at 7.2 m and 12.8 m). These PSA responses were associated with immune-related endocrinopathy but were not consistently correlated with declines in adrenal androgens. One pt had resolution of measurable disease on abdominal CT scan. Immunomonitoring studies showed T cell and dendritic cell activation, more pronounced at higher doses. Biopsies of injection sites showed T cell infiltration. Multiple tumor-reactive antibodies (abs) induced by tx were identified by serologic analysis (SEREX), including abs to filamin B. Screening against 20 defined prostate cancer antigens demonstrated induction of abs to PSMA and NY-ESO-1. Conclusions: The GVAX IT and ipilimumab combination is active in mHRPC. There was an association between PSA response and immune-related adverse events. The PSA responses cannot be accounted for by adrenal insufficiency. The relationship between clinical activity and serologic response to identified antigens is under investigation. Tx of 16 additional pts is planned.

No significant financial relationships to disclose.

A dose-escalation trial of GM-CSF-gene transduced allogeneic prostate cancer cellular immunotherapy in combination with a fully human anti-CTLA antibody (MDX-010, ipilimumab) in patients with metastatic hormone-refractory prostate cancer (mHRPC)

2500

Background: A Phase 1 trial is underway to study the combination of GM-CSF-gene-transduced allogeneic prostate cancer cellular immunotherapy (GVAX immunotherapy (IT) and ipilimumab in patients (pts) with mHRPC. Ipilimumab is a fully human IgG monoclonal antibody specific to the CTLA-4 receptor on T cells that augments immune responses by blocking the inhibitory CTLA-4/B7 interactions. Pre-clinical studies of antibodies to CTLA-4 in combination with GM-CSF secreting tumor cell vaccines demonstrate potent synergy. Methods: Eligible pts have documented mHRPC and are chemotherapy-naïve. All pts receive a 500 million cell priming dose of GVAX IT on day 1 followed by bi-weekly intradermal treatments (tx) of 300 million cells for a 24 week (wk) period. Ipilimumab is administered every 4 wks starting on day 1 for the same period. Pts are enrolled in cohorts of 3; each cohort is assigned an escalating dose of ipilimumab: 0.3, 1, 3 or 5 mg/kg. PSA is measured every 4 wks, and tumor assessments performed every 12 wks. 15 pts will be enrolled at the maximum tolerated dose. Pts are followed for disease progression and survival. Results: Ten pts have been enrolled. All 6 pts in Cohorts 1 and 2 have completed tx and are in follow-up; 5 of 6 completed all planned tx. Three pts in Cohort 3 have completed 75% of tx and are on-going. One pt in Cohort 4 has completed 25% of tx and is on-going. No dose-limiting or immune mediated toxicities have been observed. The most common adverse event is injection site reaction which occurs in 100% of pts. PSA responses by NCI working group criteria include 1 partial response (PR), 4 stable disease (SD), and 4 progressive disease (PD). Of note, 3 PD occurred in Cohort 1; 2 SD and 1 PD occurred in Cohort 2, and 1 PR and 2 SD occurred in Cohort 3. Any decline in PSA was evident within 2–4 wks of initiating tx. Conclusions: The combination of GVAX IT and ipilimumab appears well-tolerated in pts with mHPRC. These preliminary data suggest a relationship between PSA response and the dose level of ipilimumab in combination with GVAX IT.

[Table: see text]

Phase I/II study of GM-CSF gene-transduced allogeneic prostate cancer cellular immunotherapy (GVAX IT) in advanced prostate cancer patients made lymphopenic by chemotherapy and infused with autologous peripheral blood mononuclear cells (MC)

14635

Background: GVAX IT has been tested in phase I/ II and is currently being tested in phase III clinical trials of patients (pts) with androgen-independent prostate carcinoma (AIPC). Immunological and PSA responses have been described in men receiving GVAX IT. Preclinical studies have shown that antitumor immune responses induced by GVAX IT could be augmented further by making animals lymphopenic and reconstituting with lymphocytes prior to vaccination. A clinical trial was designed to study the effects of lymphopenic reconstitution in pts with AIPC. Methods: All pts had MC collection by leukapheresis pre-treatment. Study groups were as follows: Arm A - GVAX IT given every two weeks for 6 months; Arm B - Cyclophosphamide (350 mg/m2 IV on days 1–3), MC infusion on day 6, GVAX IT on day 7, then every 2 weeks for 6 months; Arm C - Cyclophosphamide (350 mg/m2 IV on days 1–3) and fludarabine (20 mg/m2 IV on days 1–3), MC infusion on day 6, GVAX IT on day 7, then every 2 weeks for 6 months. Results: Seven pts have been treated thus far and completed at least 2 GVAX IT treatments. Pts had ECOG performance status ≤ 1, castrate testosterone levels, ≤ 1 prior chemotherapy regimen and measurable or evaluable metastatic AIPC. Lymphopenia was induced in all pts enrolled in Arms B and C, with recovery of total granulocytes and lymphocytes within 4 weeks following treatment. Monitoring of humoral and cellular immunological responses is underway and shall be presented. Conclusions: GVAX IT and lymphopenic reconstitution is feasible in men with AIPC. Analysis of clinical and immune response is ongoing. Supported by DAMD grant PC020094 and generous support of Mr. Tom Denhart, the Chiles Foundation and the Murdock Trust.

[Table: see text]

Standards of nutritional care in pediatric oncology: results from a nationwide survey on the standards of practice in pediatric oncology. A Children's Oncology Group study

BACKGROUND

The prevalence of malnutrition in children with cancer ranges between 8% and 60%. Malnutrition is strongly associated with the nature of treatment and increases an individual's risk of infection. Clinical studies have suggested that nutrition intervention may decrease toxicity and improve survival in the oncology population. In order to identify the standards of practice in the nutritional management of a child with cancer, we conducted an international survey in institutions that are part of the Children's Oncology Group (COG) consortium.

PROCEDURE

Surveys were submitted to 233 participating COG institutions. We requested one member in three disciplines complete the survey: physician, registered dietitian, and nurse or nurse practitioner. The survey was returned to the nutrition sub-committee of COG.

RESULTS

Fifty-four percent of institutions responded to the survey. We found no consistency in the provision of nutrition services. Assessment of nutritional status does not routinely occur and different indices are employed to indicate the nutrition status of a patient. Institutions rely upon different guidelines when categorizing malnutrition. When nutrition intervention is clinically indicated, a variety of approaches are employed.

CONCLUSIONS

This survey did not find standardized nutrition protocols being employed in the pediatric oncology population. The effect of varied nutrition practices on the quality of life, toxicity, and outcome in children with cancer is unknown. Prior to the initiation of clinical trials, uniform guidelines need to be developed and validated. Future clinical trials need to investigate the most efficacious method of nutrition assessment and intervention and its effect on quality of life, toxicity, and survival in children with cancer.

Mortality in overweight and underweight children with acute myeloid leukemia

CONTEXT

Current treatment for acute myeloid leukemia (AML) in children cures about half the patients. Of the other half, most succumb to leukemia, but 5% to 15% die of treatment-related complications. Overweight children with AML seem to experience excess life-threatening and fatal toxicity. Nothing is known about how weight affects outcomes in pediatric AML.

OBJECTIVE

To compare survival rates in children with AML who at diagnosis are underweight (body mass index [BMI] < or =10th percentile), overweight (BMI > or =95th percentile), or middleweight (BMI = 11th-94th percentiles).

DESIGN, SETTING, AND PARTICIPANTS

Retrospective review of BMI and survival in 768 children and young adults aged 1 to 20 years enrolled in Children's Cancer Group-2961, an international cooperative group phase 3 trial for previously untreated AML conducted August 30, 1996, through December 4, 2002. Data were collected through January 9, 2004, with a median follow-up of 31 months (range, 0-78 months).

MAIN OUTCOME MEASURES

Hazard ratios (HRs) for survival and treatment-related mortality.

RESULTS

Eighty-four of 768 patients (10.9%) were underweight and 114 (14.8%) were overweight. After adjustment for potentially confounding variables of age, race, leukocyte count, cytogenetics, and bone marrow transplantation, compared with middleweight patients, underweight patients were less likely to survive (HR, 1.85; 95% confidence interval [CI], 1.19-2.87; P = .006) and more likely to experience treatment-related mortality (HR, 2.66; 95% CI, 1.38-5.11; P = .003). Similarly, overweight patients were less likely to survive (HR, 1.88; 95% CI, 1.25-2.83; P = .002) and more likely to have treatment-related mortality (HR, 3.49; 95% CI, 1.99-6.10; P<.001) than middleweight patients. Infections incurred during the first 2 courses of chemotherapy caused most treatment-related deaths.

CONCLUSION

Treatment-related complications significantly reduce survival in overweight and underweight children with AML.

Therapy-related changes in body size in Hispanic children with acute lymphoblastic leukemia

BACKGROUND

The objective of this study was to examine changes over time in body mass index (BMI) from diagnosis through chemotherapy for pediatric patients with B-precursor acute lymphoblastic leukemia (ALL).

METHODS

The study cohort consisted of 141 white Hispanic pediatric patients who were diagnosed with ALL and were treated at 2 South Texas pediatric oncology centers between 1993 and 2002. Changes in age-standardized and gender-standardized BMI scores were assessed.

RESULTS

The study cohort exhibited a steady increase in age-adjusted and gender-adjusted BMI scores for the first 12 months of therapy, a modest increase in BMI scores during the 18-23 month and 24-29 month periods, followed by a slight decrease in BMI scores at 30 months (end of therapy). A repeated-measures analysis indicated significant effects for time (P = 0.019) and time by baseline BMI category interaction (P = 0.0001) but no significant interaction effect between time and gender (P = 0.65).

CONCLUSIONS

Although it is known that leukemia therapy is associated with prevalent obesity in survivorship, its pattern of development during therapy has not been elucidated. In the current cohort of Hispanic children with ALL, BMI scores were elevated at diagnosis (mean +/- standard deviation standardized BMI Z score, 0.33 +/- 1.4), then increased, and remained elevated for the entire duration of chemotherapy. Patients who were classified as normal weight exhibited an increase in BMI over time; patients who were classified as overweight at diagnosis exhibited BMI patterns that were relatively stable; and patients who were classified as obese exhibited a very slight decline over time. These findings suggest that the risk for chemotherapy-related weight gain applies predominantly to children who begin ALL therapy within a normal weight range.

Early changes in apoptosis and proliferation following primary chemotherapy for breast cancer

Patients undergoing primary chemotherapy for invasive breast cancer consented to a core biopsy of the invasive breast primary pre- and 24 h postchemotherapy. The resulting tissue was analysed for apoptosis, Ki67, ER and HER-2 using immunohistochemical techniques. These data were then used to evaluate the relationship between these biological markers and response to chemotherapy and overall survival. Response rate to chemotherapy in this group was 86%, 16 patients (25%) achieved a clinical complete response and 41 (63%) a partial response. Prechemotherapy there was a significant correlation between Ki67 and apoptotic index (AI), r=0.6, (P<0.001). A significant rise in AI (P<0.001), and fall in Ki67 (P=0.002) was seen 24 h following chemotherapy. No relationship was seen between pretreatment AI and clinical response, but higher Ki67 and growth index (Ki67/AI ratio, GI) did correlate with clinical response (both r=0.31, P<0.025). No correlation was seen between the change in AI or Ki67 at 24 h and clinical response or survival. Significant changes in apoptosis and proliferation can be demonstrated 24 h following chemotherapy, but these changes do not relate to clinical response or outcome in this study. Pretreatment proliferation and GI are however predictive of response to chemotherapy in breast cancer.

Catheter fracture: a rare complication of totally implantable venous devices

The use of totally implantable venous devices (TIVDs) has revolutionised the care and quality of life of oncology patients. Although considered to be generally safe, catheter fracture is a rare but serious complication. The 'pinch-off' syndrome is caused by the compression of the catheter between the clavicle and first rib, and may lead to fracture and possible dislocation of the catheter. We report here the case history of two patients with metastatic breast cancer who developed the 'pinch-off' syndrome, first recognised by difficulty in line aspiration and pain during injection of the catheter. In one case, there was complete fracture with migration of the catheter tip to the right pulmonary artery. In both cases, the lines were removed without serious injury to the patient. All patients with TIVDs should be investigated for possible catheter fracture if they develop pain over the superior anterior chest wall and/or there is difficulty or pain during aspiration or injection.

Bone marrow transplantation for myelodysplastic syndrome--who? when? and which?

Although allogeneic transplantation has resulted in long-term disease-free survival in some patients with myelodysplastic syndromes (MDS), the morbidity and mortality of this approach remains high. Additionally, many patients are not candidates for such an approach because of their age or comorbid factors. Autologous transplantation and the use of reduced intensity conditioning prior to allogeneic stem cell transplantation has provided less toxic alternatives as well as increased the numbers of patients eligible for some form of transplantation. While bone marrow transplantation clearly has a role in the treatment of MDS, the decision to proceed to transplantation is not always easy and the optimal approach has not been clearly defined. Improvement in patient selection and novel approaches to transplantation will hopefully allow for more effective, less toxic results.

Cyclooxygenase-2 (COX-2), aromatase and breast cancer: a possible role for COX-2 inhibitors in breast cancer chemoprevention

Interest in chemoprevention in oncology using suppressants of prostaglandin (PG) synthesis has been stimulated by epidemiological observations that the use of aspirin and other non-steroidal inflammatory drugs (NSAIDs) is associated with reduced incidence of some cancers, including cancer of the breast. The main target of NSAID activity is the cyclooxygenase (COX) enzyme. Two isoforms of COX have been identified: COX-1, the constitutive isoform; and COX-2. the inducible form of the enzyme. COX-2 can undergo rapid induction in response to many factors such as bacterial lipopolysaccharides, growth factors, cytokines and phorbol esters. COX-2 is overexpressed in some malignancies including carcinoma of the breast. It has been suggested that such enhanced expression may lead to increased angiogenesis such that the inhibition of COX-2 might have a general anticancer effect via decreased blood vessel formation. In addition, an association between COX-2, its main product PGE2 and aromatase activity in human breast cancer suggests that such inhibitors might have an additional, specific prophylactic mechanism for this tumour. New COX-2 inhibitors are already licensed for use in the treatment of arthritis and are well tolerated. Their potential role in chemoprevention of mammary carcinogenesis in rats has already been investigated. What remains to be seen is if these findings can be extrapolated to human studies.

HER-2 amplification impedes the antiproliferative effects of hormone therapy in estrogen receptor-positive primary breast cancer

In experimental models, human epidermal growth factor receptor-2 (HER-2) amplification leads to estrogen independence and tamoxifen resistance in estrogen receptor (ER)-positive human breast cancer cells. Some but not all reports suggest an association between HER-2 positivity and hormone independence in breast cancer patients. This study aimed to evaluate the antiproliferative effects of endocrine therapy in HER-2-positive/ER-positive primary human breast cancer. The effect on proliferation (Ki67) of hormone therapy was assessed at 2 weeks and/or 12 weeks in biopsies from 115 primary breast cancers with ER-positive tumors. The patients took part in one of 3 neoadjuvant trials of hormonal therapy with a SERM (tamoxifen or idoxifene) or an aromatase inhibitor (anastrozole or vorozole). HER-2 status was assessed by immunocytochemistry and fluorescence in situ hybridization (FISH). Fifteen patients were defined as HER-2 positive by both immunohistochemistry and FISH, with the remaining 100 patients HER-2 negative. Geometric mean Ki67 levels were substantially higher in HER-2-positive than HER-2-negative tumors (27.7% versus 11.5%, respectively; P = 0.003). In HER-2-negative patients, Ki67 was reduced by 62 and 71% at 2 and 12 weeks, respectively (P < 0.0001 for both), but HER-2-positive patients showed no significant fall. The proportional change in Ki67 was significantly different between HER-2-positive and -negative patients (P = 0.014 at 2 weeks; P = 0.047 at 12 weeks). Mean ER levels were lower in the HER-2-positive patients (P = 0.06) but the change in Ki67 was impeded even in those with high ER. Apoptotic index was reduced by 30% at 2 weeks in the HER-2-negative group. However, there were no statistically significant differences in apoptotic index between the groups. It is concluded that ER-positive/HER-2-positive primary breast carcinomas show an impeded antiproliferative response to endocrine therapy that nonetheless may vary between individual treatments. This together with high baseline proliferation is likely to translate to poor clinical response.

Understanding the experience of prophylactic bilateral mastectomy: a qualitative study of ten women

Prophylactic bilateral mastectomy represents a new and controversial cancer prevention strategy for women at high-risk of familial breast cancer, the psychosocial implications of which are yet to be fully explored. A qualitative methodology was therefore adopted to provide a discovery-orientated study of the perspectives of ten women who had undergone prophylactic mastectomy and the views of eight of their partners. Each participant was interviewed with the aim of exploring the personal experiences of surgery, factors associated with psychological adjustment and the impact on the family. Data were transcribed and systematically analysed using Grounded Theory. Themes emerging from participants' accounts formed seven significant categories that represented women's key experiences: (i) deciding; (ii) telling; (iii) experiencing surgery and recovering; (iv) maintaining womanliness; (v) processing the loss; and (vi) moving on. The importance of the social context in women's experience and difficulties of isolation/eliciting support were also highlighted: (vii) isolation and being supported. A core category of 'Suffering and countering multiple loss' considered central to women's experience, integrated the seven significant categories and provided further conceptualisation of women's experience. Implications for clinical practice are highlighted.

Are randomized trials of hormone replacement therapy in symptomatic women with breast cancer feasible?

OBJECTIVE

To evaluate the feasibility of conducting a large randomized trial of HRT in symptomatic women with early-stage breast cancer.

DESIGN

Open randomized study.

SETTING

Outpatient clinics at The Royal Marsden and St. George's Hospitals, London.

PATIENT(S)

One hundred postmenopausal women with early-stage breast cancer, experiencing vasomotor symptoms and/or vaginal dryness.

INTERVENTION(S)

Randomization (1:1) to HRT or no HRT for 6 months.

MAIN OUTCOME MEASURE(S)

Acceptance, continuance rates, and the reasons eligible women declined study entry.

RESULT(S)

Acceptance (38.8%) and continuance rates (>80%) were encouraging. The efficacy of HRT did not appear to be antagonized with concomitant tamoxifen. Seventy-five percent of women continued HRT after the study ended. Three women developed metastatic disease. Two used HRT.

CONCLUSION(S)

Despite informed consent, a national UK randomized trial of HRT should be feasible and has now been planned. Successful implementation necessitates the provision of information about HRT and the estrogen deficiency side effects of breast cancer therapy to health professionals and women with breast cancer.

Local relapse in primary breast cancer patients with unexcised positive surgical margins after lumpectomy, radiotherapy and chemoendocrine therapy

BACKGROUND

Inadequate surgical excision with residual involvement of resection margins by tumour after breast conservation results in increased local recurrence rates. To reduce this risk positive margins are, therefore, usually excised. Systemic treatment with tamoxifen or chemotherapy reduces local recurrence, along with radiotherapy. However, no studies to date have examined the correlation between chemoendocrine treatment, together with radiotherapy, and local relapse in patients with unexcised involved resection margins, having had breast conservation treatment.

PATIENTS AND METHODS

The histopathology reports were reviewed of 184 patients who were treated from June 1991 to August 1995 within our randomised study of neoadjuvant versus adjuvant chemoendocrine therapy with mitozantrone and methotrexate (2M) +/- mitomycin-C (3M) and tamoxifen, used concurrently with radiation following conservation surgical treatment. Histological resection margin was considered positive if ductal carcinoma in situ (DCIS) or invasive carcinoma was present microscopically less than 1 mm from the excision margin.

RESULTS

Although 38% of patients had unexcised microscopically involved margins, local relapse rate as first site of relapse was only 1.9% after a median follow up of 57 months. There was no difference in distant relapse (P = 0.2) and survival (P = 0.5) between the positive and negative margins groups.

CONCLUSIONS

The presence of positive unexcised margins does not have a significant effect on outcome in patients who are treated with chemoendocrine therapy together with radiotherapy. Further clinical trials are required.

Family history of breast cancer: what do women understand and recall about their genetic risk?

The current study has two aims: (1) to look at people's recall of risk information after genetic counselling and (2) to determine the impact of receiving an audiotape of the genetic consultation on level of recall, cancer related worry, and women's uptake of risk management methods. Using a prospective randomised controlled design, subjects receiving an audiotape were compared with a standard consultation group. Participants were drawn from attenders at the genetic clinics of two London hospitals and included 115 women with a family history of breast cancer. Assessment of perceived genetic risk, mental health, cancer worry, and health behaviour was made before counselling at the clinic (baseline) and by postal follow up. Usefulness of audiotapes and satisfaction with the clinical service was assessed by study specific measures. The data indicate that cancer worry is reduced by provision of an audiotape of the genetic consultation. Recall of the genetic risk figure, however, is not affected by provision of an audiotape and neither is it related to women's overall perception of being more or less at risk of breast cancer than the average woman. Forty-one percent of women accurately recalled their personal risk of breast cancer at one month follow up; however, 25% overestimated, 11% underestimated, and 23% could not remember or did not know their breast cancer risk. Recall of the risk figure is more accurate when the clinical geneticist has given this to the woman as an odds ratio rather than in other formats. Subsequent health behaviour is unaffected by whether women have an audiotape record of their genetic consultation. Results suggest that having a precise risk figure may be less important than women taking away from the consultation an impression that something can be offered to help them manage that risk. Provision of an audiotape of the consultation is of limited usefulness. The need for psychological care to be better integrated into genetic counselling at cancer family clinics was highlighted by the study. The results are discussed in terms of future service development.

Clinical prognostic and predictive factors for primary chemotherapy in operable breast cancer

PURPOSE

This study aimed to identify clinical factors that are of prognostic significance or that predict for subsequent treatment outcome in patients with large operable breast cancer treated with primary chemotherapy (PCT) at our institution.

METHODS

One hundred eighty-five patients received the following regimens: CMF or MMM (76 patients), ECF (75 patients), AC or FEC (34 patients), followed by surgery, with radiotherapy (RT) given to those with breast conservation. A number of common clinical variables were assessed in relation to local recurrence-free survival (LRFS), disease-free survival (DFS), and overall survival (OS).

RESULTS

Clinical responders had improved DFS (P = .009) and OS (P = .08) compared with nonresponders. There was no association between clinical or pathologic complete remission (CR) and survival. Pretreatment clinical axillary node positivity was a significant predictor of worsened DFS (P = .0001), OS (P = .0001), and LRFS (P = .03). Patients remaining clinically node-positive postchemotherapy had an inferior outcome compared with those becoming node-negative (DFS, P = .03; OS, P = .03) but pathologic axillary node status was not shown to predict for survival. Twenty-nine patients in clinical CR following PCT who electively did not have surgery and were treated with RT alone had significantly increased local recurrence rate compared with partial responders having surgery and RT (P = .02). There were no differences in DFS or OS between these groups. On multivariate analysis, clinical axillary node status was the only independent predictor of OS and DFS, and LRFS.

CONCLUSION

Pretreatment and posttreatment clinical axillary node status is a major predictor of outcome following PCT. Complete clinical response does not define a more favorable subgroup compared with those not obtaining CR.

The detection of micrometastases in the peripheral blood and bone marrow of patients with breast cancer using immunohistochemistry and reverse transcriptase polymerase chain reaction for keratin 19

The aim of this study was to determine whether reverse transcriptase polymerase chain reaction (RT-PCR) for keratin 19 (K19) provides additional information when combined with immunohistochemistry when used to detect micrometastases in blood and bone marrow in patients with primary breast cancer. We studied 78 patients with breast cancer who had no evidence of distant metastases. We collected blood and bone marrow, separated the mononuclear fraction and carried out RT-PCR and immunohistochemistry for K19. RT-PCR was done by two 40-cycle rounds using nested primers. In initial experiments, RT-PCR was shown to be capable of detecting one tumour cell in one million normal bone marrow cells, which was at least 10 times more sensitive than immunohistochemistry, while retaining specificity. Five per cent of the peripheral blood and 22% of the bone marrow samples contained K19 positive cells by immunohistochemistry staining. Using RT-PCR, these proportions increased to 25% and 35%, respectively. This represents a significantly greater detection frequency (P < 0.001 and P = 0.03, respectively). RT-PCR for K19 is a more sensitive method for detecting micrometastases in patients with primary breast cancer when compared with immunohistochemistry.

Re-excision operations in nonpalpable breast cancer

We retrospectively reviewed the records of 317 needle-localization (NL) biopsies performed at the Royal Marsden Hospital during 1989-1992. The malignancy yield in our centre, where there is an emphasis on cooperation with an experienced radiologist and breast pathologist, was 48% (151/317), with benign to malignant biopsy ratio of 1:1:1. Analysis of the histopathological findings of the malignant lesions revealed a 45% (68/51) incidence of positive microscopic margins. Of these 68 patients, 50 had re-excisions, including nine patients who required mastectomy. Twenty-eight of the re-excisions (56%) contained residual tumour, of which five (18%) were invasive carcinoma > 3 mm (size range 1-19 mm) and 13 (46%) were residual DCIS > 1 mm (size range 1-40 mm). Our findings suggest a significant incidence of residual disease associated with positive microscopic margins in NL-detected nonpalpable cancers. Therefore, our current practice of performing a wider re-excision for positive margins is justified. Stereotactic fine-needle aspiration cytology was not performed by the radiologist referring these cases, but it should be performed preoperatively and if the test is positive, definitive treatment in the form of wide local excision or quadrantectomy is carried out in the first instance in order to avoid a second-surgical procedure.

Randomized trial of chemoendocrine therapy started before or after surgery for treatment of primary breast cancer

PURPOSE

To evaluate in a randomized clinical trial systemic chemoendocrine therapy used as primary (neo-adjuvant) treatment before surgery in women with primary operable breast cancer.

PATIENTS AND METHODS

Patients aged less than 70 years with clinically palpable, primary operable breast cancer diagnostically confirmed by fine-needle aspiration cytology (FNAC) and suitable for treatment with surgery, radiotherapy, cytotoxic chemotherapy, and tamoxifen were considered eligible. Patients randomized to neoadjuvant treatment received four cycles of chemo-therapy for 3 months before surgery followed by another four cycles after surgery, and were compared with patients randomized to adjuvant therapy who received eight cycles of chemotherapy over 6 months after surgery.

RESULTS

Of 212 patients who were randomized to receive either adjuvant (n = 107) or neoadjuvant (n = 105) chemoendocrine therapy, 200 are now assessable for response. The two groups are comparable for age, menopausal status, disease stage, and surgical requirements. The overall clinical response rate was 85%, with a complete histologic response rate of 10%. There was a significant reduction in the requirement for mastectomy in patients who received neoadjuvant treatment (13%) as compared with those who received adjuvant therapy (28%) (P < .005). Symptomatic and hematologic acute toxicity was low and similar for adjuvant and neoadjuvant therapy. The median follow-up period for patients in this trial is 28 months, during which time four patients have relapsed locally and 20, including one of the local relapses, have developed metastatic disease, 19 of whom have died. The follow-up period is too brief to evaluate relapse rate or survival duration.

CONCLUSION

This trial confirms previous reports of a high rate of response to neoadjuvant therapy, but is the first to include small primary cancers and to show, in the context of a randomized trial, a reduction in the requirement for mastectomy. Until disease-free and overall survival data are available from the larger National Surgical Adjuvant Breast and Bowel Project (NSABP)-18 trial, such neoadjuvant treatment cannot be recommended outside of a clinical trial.

Determining factors which predict response to primary medical therapy in breast cancer using a single fine needle aspirate with immunocytochemical staining and flow cytometry

The increasing use of neoadjuvant chemotherapy and endocrine therapy in the management of breast cancer has lead us to evaluate and optimise the standard technique of cytocentrifugation of a single fine needle aspirate (FNA) taken from a breast tumour in-vivo, to determine a range of both immunocytochemical and flow cytometric factors which are predictive of response to primary medical therapy. Some of these factors are also of prognostic significance in early stage disease. An analysis of the cellularity and immunocytochemical staining characteristics of FNAs obtained from a series of 206 patients with palpable breast cancers indicate that in a sample of 46 cases it is possible to measure oestrogen receptor, progesterone receptor and c-erbB-2 providing over 400 cells per slide are obtained, with material obtained in a single FNA prepared by cytocentrifugation, using standard immunocytochemical methods. The staining results obtained were comparable to those obtained using frozen or paraffin embedded tissue sections taken from the same tumour. In addition an estimate of the proliferation indices could be made by flow cytometric analysis of the residual cell suspension fluid with measurement of DNA index and S-phase fraction in 131/164 (80%) and 110/164 (67%) of cases respectively. Providing all FNAs obtained for cytocentrifugation were taken at first presentation rather than immediately following a standard FNA, then it was possible to obtain adequately cellular (> 400 cells/slide) samples in 96 out of 126 (75%) of the last cohort of breast aspirates. These effects may be independent of T stage but not histological type as patients with lobular tumours only produced cellular aspirates in 1/7 (14%) of cases.(ABSTRACT TRUNCATED AT 250 WORDS)

High complete remission rates with primary neoadjuvant infusional chemotherapy for large early breast cancer

PURPOSE

To investigate the efficacy of continuous infusion fluorouracil (5FU) with every-3-week epirubicin and cisplatin (ECF) as primary chemotherapy instead of immediate mastectomy for patients with large, potentially operable, breast cancer.

PATIENTS AND METHODS

Fifty patients with large operable breast cancer, median tumor diameter 6 cm (range, 3 to 12), were treated with 5FU 200 mg/m2/d via a Hickman line using an ambulatory pump for 6 months with epirubicin 50 mg/m2 intravenously (IV) and cisplatin 60 mg/m2 IV every 3 weeks for eight courses. Subsequent surgery and/or radiotherapy was determined by clinical response.

RESULTS

Forty-nine patients achieved an overall response (98%; 95% confidence interval [CI], 94% to 100%), including 33 complete clinical remissions (CRs) (66%; 95% CI, 53% to 79%). Only three patients (6%) still required mastectomy. Tumor cellularity was markedly reduced on repeat needle biopsy following 3 weeks of treatment in 81% of patients versus only 36% in similar patients after conventional chemotherapy (P < .002). Severe (World Health Organization [WHO] grade 3 to 4) toxicity was rare, with nausea/vomiting being the most common, occurring in 20% of patients.

CONCLUSION

Primary infusional ECF appears to be more active on clinical and histopathologic grounds than conventional chemotherapy for large operable breast cancer and is well tolerated. This approach now merits randomized comparison to determine if high CR rates may translate into improved survival.

A phase II study in advanced gastro-esophageal cancer using epirubicin and cisplatin in combination with continuous infusion 5-fluorouracil (ECF)

PURPOSE

A phase II study was performed in patients with unresectable or metastatic gastric cancer evaluating the efficacy of a new chemotherapy schedule combining epirubicin and cisplatin with a continuous ambulatory infusion of 5-fluorouracil (ECF).

PATIENTS AND METHODS

One hundred thirty-nine consecutive, previously untreated patients were given ECF. Of these, 128 had measurable disease. Epirubicin (50 mg/m2 i.v.) and cisplatin (60 mg/m2 i.v.) were administered every three weeks for 8 cycles during a 21 week continuous i.v. infusion of 5-fluorouracil (200 mg/m2/day). In total 773 cycles of chemotherapy were given.

RESULTS

Objective tumour responses was seen in 91 (71%) of the 128 patients with measurable disease, of which 15 (12%) had a complete response. Twenty patients with locally advanced disease responding to ECF had attempted resection of the primary--11 (55%) were completely removed, 4 of these had no residual tumour in the resected specimen. The overall median survival was 8.2 months with 1 and 2 year survivals of 30% and 10% respectively. Grade 3 or 4 emesis occurred in 13%, stomatitis in 7%, diarrhoea in 4%, infection in 6%, leucopenia in 21% and thrombocytopenia in 8% of patients. Myelosuppression delayed treatment in 39 (5%) of the 773 cycles. Six of the 139 patients (4.3%) had treatment related deaths. There was no measurable reduction in quality of life during chemotherapy, while 67% of the 66 patients with dysphagia had complete resolution of this symptom.

CONCLUSIONS

The ECF regimen displays high anti-tumour activity with moderate toxicity in patients with gastric cancer and in some cases enabled resection of previously inoperable tumours.

The Royal Marsden Hospital pilot tamoxifen chemoprevention trial

A pilot randomised placebo controlled trial using tamoxifen in healthy women at increased risk of developing breast cancer, has been undertaken in order to evaluate the problems of accrual, acute symptomatic toxicity, compliance, and safety as a basis for subsequent large national multicentre trials designed to test whether tamoxifen can chemoprevent breast cancer. From October 1986 until June 1993, 2012 healthy women with an increased risk of developing breast cancer, usually because of a strong family history, were randomly allocated to receive tamoxifen 20 mgs/day or placebo for up to 8 years if possible. Accrual remained high in spite of extensive informed consent regarding potential risk. Acute symptomatic toxicity was low for participants on tamoxifen or placebo and compliance remained correspondingly high with a predicted 77% of women on tamoxifen and 82% of women on placebo continuing medication at 5 years. There was a significant increase in hot flushes (34% versus 20%) mostly in premenopausal women (p < 0.005), vaginal discharge (16% versus 4%, p < 0.005), and menstrual irregularities (14% versus 9%, p < 0.005). The requirements for hormone replacement therapy for women on tamoxifen or placebo were the same. Safety monitoring indicates no adverse anti oestrogenic effects of tamoxifen. There was no obvious effect of tamoxifen on bone mineral densities (single photon radial absorption). The fibrinogen and antithrombin III were both lowered, resulting in no observed detrimental effect on the ratio of these clotting factors. There was a significant reduction in the serum cholesterol maintained out to 5 years. Annual pelvic assessment using transvaginal ultrasound indicates an increased incidence of uterine fibromata and benign ovarian cysts.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunocytochemical staining for the c-erbB-2 gene product in breast aspirates: a preliminary report

The results of the determination of c-erbB-2 gene expression by immunocytochemical staining of cytological aspirates, prepared by cytocentrifugation, have been compared with paraffin-embedded tissue sections from the same tumour. Our results show equivalent staining in 20/22 cases, with six cases being both scored positive and fourteen cases being both negative. Two samples gave conflicting results. One case was scored as being positive on the cytological aspirate, whereas in the tissue sections taken from the same tumour positive staining was only seen in areas of non-invasive intraduct carcinoma. This sample was scored as being negative. In another case, cytoplasmic staining with less than 50% of the cells showing any positivity was observed in the cytospin sample, with negative staining in the corresponding tissue section. We conclude that expression of c-erbB-2 immunostaining is detectable on cytological preparations prepared by cytocentrifugation but must be interpreted with caution in tumours which may have a large intraduct component or which give predominant cytoplasmic staining.

The impact of parental affective disorder on depression in offspring: a longitudinal follow-up in a nonreferred sample

OBJECTIVE

This study explored the effects of parental affective disorder on offspring in a nonreferred health maintenance organization 4 years after initial examination.

METHOD

The sample, average age 18.5 years, included 91% of the 153 youngsters initially studied. The main instruments were structured diagnostic interviews scored according to criterion systems for both parents and children; assessment of the youngsters was blind to the previous assessment.

RESULTS

Rates of major depressive disorder were higher in the children of parents with affective disorder (26%) compared with those whose parents had no disorder (10%).

CONCLUSION

Depression and other parental affective disorders, as they occur in the community in parents who often are neither recognized nor treated, are associated with serious affective disorder in offspring. Clinical and preventive approaches for these offspring are needed and should be targeted to all families in which there is serious parental affective disorder, not just those who present for psychiatric treatment.

Radioimmunolocalisation in breast cancer using the gene product of c-erbB2 as the target antigen

Lymph node status is still the single most important prognostic factor in breast cancer. Axillary surgery remains the only reliable means of providing this information. This pilot study evaluates using a highly specific radiolabelled monoclonal antibody to provide equivalent information by a non-invasive technique. After optimisation of labelling conditions, our first antibody, ICR12 (against the gene product of c-erbB-2) was evaluated in a mouse model system. Twenty-four hours post i.v. injection the mice were killed and their organs, blood and tumours harvested for counting. Tumour localisation was four times greater than that into normal tissues, reaching 20% injected dose per gram of tumour. Eight patients have had this Tc99m-ICR12. Patient selection was by immunocytochemical staining of fine needle aspirates from the patient's own breast cancer. After intravenous administration of the immunoconjugate, tomographic images were obtained at 24 h. These results were compared to the subsequent histopathological examinations. Three patients acted as normal controls, one patient was negative due to inappropriate sampling, and two patients had strong membrane staining and provided excellent tumour localisation to both breast primary and regional node metastases. A further two patients only had moderate antigen expression on staining and did not localise well. The good performance of this radiolabelled antibody with patients that strongly stain for the antigen encourages the development of this system as both a method of staging breast cancer and a potential means of immunotherapy in this subgroup of patients.

Primary medical (neo-adjuvant) chemotherapy for operable breast cancer

84 patients with large operable breast cancer have been treated with primary medical chemotherapy rather than mastectomy in three sequential studies. 86% had tumours greater than 4 cm in diameter; median diameter was 6 cm (range 1-12). Median age was 46 years (range 23-66). In the first two studies 64 patients were treated with either CMF [cyclophosphamide 100 mg orally days 1-14, methotrexate 50 mg intravenously (i.v.) days 1 and 8, and 5-fluorouracil 1 g i.v. days 1 and 8, repeating at 28-day intervals for six courses] or MMM (mitozantrone 8 mg/m2 i.v. once every 3 weeks, methotrexate 50 mg i.v. once every 3 weeks, mitomycin C 8 mg/m2 once every 6 weeks, for 8 courses). 69% achieved an overall response including 17% complete remissions. 27% have had local relapse but only 3% uncontrolled local relapse. Only 14% have required mastectomy. In the third study which is ongoing, 19 patients have been treated with infusional FEC (5-fluorouracil 200 mg/m2 i.v. 24 hourly by continuous infusion via a Hickman line for 6 months, epirubicin 50 mg/m2 i.v. bolus once every 3 weeks for 6 months, cisplatin 60 mg/m2 i.v. once every 3 weeks for 6 months with appropriate intravenous hydration). Overall response rate so far is 84% with 58% complete remissions. There have been no local relapses and no patient has required mastectomy. This study demonstrates that primary medical chemotherapy can be used to avoid mastectomy in the great majority of patients presenting with large operable primary breast cancer. Infusional FEC may be more active than conventional chemotherapy in terms of overall response and complete remission rate, and infusional FEC chemotherapy now needs to be compared with conventional chemotherapy. The concept of primary medical therapy should also be compared with conventional mastectomy followed by adjuvant chemotherapy.

Gastrointestinal priming prior to full enteral nutrition in very low birth weight infants

Priming of the gastrointestinal (GI) tract with low-volume feedings before giving full enteral feedings to very premature, high-risk infants is a controversial practice. We designed a study of infants weighing less than 1,250 g and receiving total parenteral nutrition to determine whether GI priming would hasten weight gain, improve tolerance of subsequent feedings, enhance nutritional status, and increase serum concentration of gastrin, a hormone trophic for intestinal growth. Infants were randomly assigned to receive total parenteral nutrition (TPN) alone (N = 21) or GI priming plus TPN (N = 19) for 12 days beginning on day 3 of life. Full-strength premature infant formula was used for priming. Both groups received the same total nutrition. Beginning on day 15, feedings in both groups were increased daily to a maximum of 120 kcal/kg/day on day 20, where they were maintained until day 30. After day 30, the feedings were modified according to the infants' condition. The groups did not differ in birth weight, gestational age, or 5-min Apgar scores. GI-primed infants had improved feeding tolerance after day 20 and a faster rise in serum gastrin during the initial phase of the study. There was no significant difference in weight gain. GI priming improves tolerance of feedings, accelerates rate of rise of serum gastrin during the first weeks of life, and does not increase the risk of feeding complications when compared to TPN alone. This may lead to more rapid maturation of the GI tract in primed infants.

The use of transfer factors in the treatment of multiple sclerosis: a case report

A 23-year-old woman suffering from multiple sclerosis (MS) was given a course of 6 injections (0.5 U) of mumps transfer factor (TF) at 2-weekly intervals. The patient's symptoms improved dramatically and during the 10 months since treatment was instituted, no exacerbations have occurred. The possible aetiological role of paramyxoviruses in MS and the use of TF in the treatment of the disease are discussed. MS is however, a disease of exacerbations and spontaneous remissions, and despite our promising findings in this patient we wish to refrain from hailing mumps TF as a possible cure for this notorious disease.