Tamoxifen as Adjuvant after Surgery for Breast Cancer and Tamoxifen or Placebo as Chemoprevention in Healthy Women: Different Compliance with Treatment

Aim

The aim of this study was to investigate whether tamoxifen toxicity and treatment discontinuations differred in the adjuvant versus chemopreventive setting.

Methods

At our Institutions 119 postmenopausal breast cancer patients were randomized from August 1987 to March 1995 to tamoxifen only within adjuvant studies (International Breast Cancer Study Group studies VII and IX) and 202 healthy hysterectomized women aged 35-70 years were randomized from November 1993 to May 1996 in a multicenter, double-blind, placebo-controlled chemoprevention study (Italian Tamoxifen Prevention Study). The tamoxifen dose was 20 mg/day for 5 years in all studies. Median age was 66 years (54-85) in the adjuvant studies and 53 years (37-69) in the chemoprevention study. Median treatment duration was 238 and 120 weeks, respectively.

Results

Patients treated within adjuvant studies experienced more hot flashes, vaginal discharge and/or bleeding, bone marrow depression and weight gain than those treated in the chemoprevention study, consistent with the fact that a proportion of women in the latter study were receiving placebo. Temporary discontinuation occurred in 2.5% of patients in the adjuvant studies and in 5.4% of women in the chemoprevention study (difference not statistically significant). Permanent discontinuation was more frequent in the chemoprevention study than in the adjuvant ones (26.7% vs 15.1% - P < 0.05).

Conclusions

In summary, our data show that, although the toxicity of tamoxifen is superimposable in the two settings, a larger proportion of women treated as chemoprevention discontinue treatment spontaneously. Due to the double-blind nature of the chemoprevention study, the impact of the toxicity of tamoxifen upon compliance in the chemopreventive setting cannot be ascertained.

Epirubicin in the Treatment of Malignant Mesothelioma: A Phase II Cooperative Study

From September 1986 to April 1988, all consecutive patients with histologically proven (pathologic review mandatory) malignant mesothelioma, measurable disease, age less than 75 years, Karnofsky performance status equal to or greater than 40, and no previous chemotherapy were treated with epiru-blcin at the dosage of 75 mg/m2 i.v. every 3 weeks. Of the 23 patients who entered the study, 2 were retrospectively found not to have malignant mesothelioma. In the 21 eligible patients (all evaluable), no complete remission, 1 partial remission, 11 stable diseases and 9 progressions were noted. Toxicity was very mild. Median survival was 7.5 months. At the dosage used, epirubicin proved to be of little value in the management of these patients. Whether higher doses are more effective, as has been noted in other tumors, remains to be ascertained.

Carcinoembryonic Antigen (CEA) in the Follow-Up of Disease-Free Breast Cancer Patients

Carcinoembryonic antigen (CEA) assays (2536) were performed in 380 disease-free breast cancer patients after radical mastectomy. In the 334 evaluable patients with 3 or more determinations, the overall relapse rate after a median follow-up of 29 months was 11 %. Of 203 patients with normal CEA values, 19 (9.3 %) relapsed. In the 50 patients with the highest CEA value greater than 20 ng/ml, the relapse rate was 26 %; in the 12 patients with gradually increasing CEA elevations it was 50 %. However, CEA was unable to predict recurrence in N- patients. Premastectomy N+ was significantly associated with greater than 20 ng/ml or gradually increasing CEA values, suggesting the lack of an independent prognostic value of CEA in our patient population.

Tamoxifen Therapy in Postmenopausal Advanced Breast Cancer: Efficacy at the Primary Tumor Site in 46 Evaluable Patients

Forty-six evaluable postmenopausal patients with locally advanced, inoperable T3-T4 breast carcinoma were treated with tamoxifen 10-20 mg twice daily for a period at least 6 weeks. Eight patients (17 %) had an objective response at the primary tumor site after 6 weeks of treatment. Improvement of response with a further single tamoxifen therapy was observed in 7 patients, resulting in an overall objective response in 14 of 46 (30 %). Median duration of response was 8 months (range 2-24). No response was obtained in the 5 patients with inflammatory signs. Toxicity of treatment was minimal. Median survival was 10 months (responders 17.5, non-responders 9). Tamoxifen seems to be a safe and effective treatment for locally advanced breast cancer without inflammatory signs in postmenopausal women.

Fourteen-Day Infusion of Ifosfamide in the Management of Advanced Breast Cancer Refractory to Protracted Continuous Infusion of 5-Fluorouracil

Aims and background

Ifosfamide is an active drug in advanced breast cancer. Short-term continuous infusion schedules have been evaluated with encouraging results. The aim of the study was to evaluate in patients with advanced breast cancer a 14-day infusion schedule previously tested at our center in soft tissue sarcomas.

Methods

From July 1998 to February 2000, 26 consecutive patients with heavily pretreated breast cancer, progressing during protracted continuous infusion of fluorouracil, were treated with ifosfamide at the dose of 800 mg/m2/day for 14 consecutive days by means of an eiastomeric pump via an indwelling Groshong catheter. The median age of the patients was 52 years (range, 32-67) and median PS was 1 (range, 1-3). All patients were pretreated with anthracyclines or taxanes; the median number of chemotherapy lines in the metastatic phase was 2 (range, 1-4). Predominant metastatic sites were soft tissues in 5 patients, lung in 6, liver in 7 and serosal cavities in 3.

Results

Twenty-four patients were assessable for response. Two complete responses and 2 partial remissions were noted, for an overall 16.6% response rate. The duration of responses was 3+, 5, 8 and 10 months, respectively. Stabilization or minor response was observed in 2 more patients. The main toxic effect was myelosuppression (grade 1-2 in 15 patients, grade 3-4 in 4). Other toxicities included nausea in 14 patients (grade 3 in 2) and grade 1-2 vomiting in 2 patients. Hair loss or alopecia was universal.

Conclusions

The regimen yielded some clinically useful responses with acceptable toxicity. Its evaluation in less advanced cases appears to be warranted.

Phase II Trial of Oral VP 16-213 (Etoposide) in Patients with Advanced Head and Neck Cancer

We tested VP 16-213 in 16 patients with advanced head and neck cancer after conventional treatments. VP 16-213 was administered orally at the dosage of 100 mg/mq for 5 consecutive days every 3 weeks. No patient achieved an objective response. Toxicity was mild. VP 16-213 given at this dose and schedule revealed no activity in pretreated patients with head and neck cancer.

Continuous Infusion Fluorouracil in the Management of Advanced Breast Cancer: A Phase II Study

AIMS AND BACKGROUND

The evaluation of unconventional schedules of well-known drugs represents a promising avenue in the search for new regimens with a better therapeutic index in metastatic breast cancer. In particular, protracted continuous infusion (PCI) of 5-fluorouracil (5-FU) has yielded interesting results in gastrointestinal malignancies and in breast cancer.

METHODS

From March 1996 30 consecutive patients with heavily pretreated breast cancer were treated with PCI 5-FU at a daily dose of 250 mg/m2 by means of disposable elastomeric pumps until progression or toxicity. The median age was 54 years (range, 28-71) and median performance status was 1 (range, 0-3). All patients but four were pretreated with anthracycline-containing regimens or taxanes; the median number of chemotherapy lines was 3 (range, 2-4). Metastatic sites were predominantly visceral in 60% of the patient population.

RESULTS

All 30 patients were evaluable for response and toxicity. The median duration of PCI was 20 weeks (range, 2-36 weeks). Two complete responses (7%) and eight partial remissions (26%) were observed, giving an overall response rate of 33%. The median duration of response was six months (range, 4-9 months). Stabilization was observed in seven patients (23%) with a median duration of seven months (range, 3-9 months). The main toxic effects were grade I-II mucositis and hematologic toxicity, while grade 3 hand-foot syndrome was observed in eight patients (27%).

CONCLUSIONS

This study confirms the efficacy and safety of 5-FU at this dosage and schedule in heavily pretreated women with advanced breast cancer. In order to improve on these results further studies are needed in a less advanced stage of the disease and together with other active drugs.

VM 26 in Advanced Mycosis Fungoides

Five consecutive patients with progressive extracutaneous stage IV mycosis fungoides (MF) were treated with VM 26, 100 mg/m2 i.v., for at least 3 cycles. All patients had been extensively pretreated and in particular with vinca alkaloids. Two partial responses of 5 and 9 + months duration and 1 minimal response of 5 months duration were obtained. Transient myelosuppression was encountered in all patients. These preliminary results should encourage further exploration of VM 26, even in less advanced MF.

Does the Information Level of Cancer Patients Correlate with Quality of Life? A Prospective Study

AIMS AND BACKGROUND

The aim of the study was to evaluate the impact of information level on quality of life in cancer patients previously studied for their information level.

PATIENTS AND METHODS

The information level was determined by means of a questionnaire that explored the degree of information on diagnosis and status of disease, the patient's interpretation of his/her disease status, and his/her satisfaction with the information received. Quality of life was evaluated, some months after evaluation of the information level, by means of the Functional Living Index for Cancer (FLIC) and the State-Trait Anxiety Inventory (STAI 1-2).

RESULTS

A total of 175 patients were studied. Information was adequate in 53.7% of patients. An adequate level of information was present more frequently among patients aged < or = 65 years and in those patients followed at a cancer institute. There was no difference in the quality of life of adequately versus inadequately informed patients. Satisfaction with the information received influenced quality of life in both age groups. Objective clinical variables (active disease present and ongoing treatment) negatively affected quality of life in patients <65 years, whereas the subjective perception of the presence of disease was associated with a worse quality of life in older patients.

CONCLUSIONS

In the study, although the level of information did not affect the quality of life, satisfaction with the information was associated with a better quality of life. The finding stresses the importance of a sensible disclosure of diagnosis and prognosis.

Oncologic Out-Patient Clinic in a General Hospital

From January 1975 to June 1979 3,007 new patients have been followed in the Out-patient Clinic of the Division of Radiotherapy and Medical Oncology of the Ospedale Civile, Fordenone. A progressive increase in the number of patients and the validity of follow-up care has been demonstrated. Patients still encounter considerable logistic difficulties, which could be reduced by programming diagnostic procedures the same day of therapy. The organization of a drug service in the Out-patient Clinic, a more active collaboration with the sanitary units working outside the Hospital, and an adequate psychological assistance could solve many of the problems which are superimposed on the direct effects of the disease.

Medical Treatment of Metastatic Renal Cell Carcinoma

Thirty five patients with metastatic RCC were observed over a 57 months period in our Division of Radiotherapy and Medical Oncology, and 30 are evaluable for this analysis. MPA was selected as primary treatment agent in 23 patients, VLB singly, in combination with MPA or in combination with CCNU was used in 1.4 and 2 patients. With MPA the TR rate was 3/23 (1 CR and 2 PR). Duration of response for the patient with CR was 6 months whereas for the patients with PR was 21 and 14 months respectively. 4 additional patients showed NC. With VLB-MPA the TR rate was 1/4 (1 PR). Duration of PR was 3 months. The median duration of survival for the 11 patients with CR, PR and NC was 14 months whereas for the 19 patients with NR was 7 months (p < 0.01). TES and TAM showed no or minimal activity as second treatment agents.

Adriamycin, Bleomycin, Vinblastine and DTIC in Advanced Diffuse Lymphocytic Poorly Differentiated Lymphoma

From January 1975 to December 1979, 14 consecutive patients with advanced (stage III-IV) diffuse lymphocytic, poorly differentiated lymphoma (DLPD) were treated with adriamycin, bleomycin, vinblastine and DTIC (ABVD). Either maintenance combination chemotherapy with CVP or radiotherapy over bulky disease was added in the cases with complete response (CR). Fifty per cent of the patients achieved CR and 80% achieved objective responses. Among CRs, 100% were alive at 2 years, 70% of them without evidence of disease. Overall, 75% of the patients were alive at 2 years, 30% without evidence of disease. Toxicity was acceptable and no drug-related deaths occurred. ABVD is not the ideal combination for DLPD, but it should be taken into consideration in patients with advanced DLPD in which first line combination chemotherapy regimens are not successful.

Clinical and Immunological Evaluation of 5 Cases of Mycosis Fungoides in Advanced Stages

Five patients with mycosis fungoides, hospitalized in the Division of Radiotherapy and Medical Oncology of the Ospedale Civile, Pordenone, from January 1975 to December 1978, were studied and treated as non-Hodgkin lymphomas. All patients had evidence of disseminated disease: 3 with bone marrow infiltration, 1 with splenic involvement and 1 with lymph node involvement. Three patients were treated with CVP, resulting in 2 complete remissions that lasted 18 months and 1 PR > 50% maintained for 7 months. One patient was treated with ABVD with a PR > 50% maintained for 10 months. The last patient was treated with prednisone and then with CV, but expired from pulmonary embolism after 1 cycle. Lymphocyte function, using E and EAC rosette and PHA, was evaluated before therapy in all patients: in the 2 patients who obtained a CR, an improvement in T-lymphocyte function was noted after therapy. The chromosome pattern of peripheral blood lymphocytes was altered before therapy in only one patient. Even if the follow-up period is still relatively brief, the duration of the 2 complete remissions must be stressed. In addition, a strict correlation between T-lymphocyte function and response to therapy was revealed in our study.

Safety of adjuvant trastuzumab (T) in elderly patients with breast cancer

282

Background: T is a mainstay in adjuvant therapy for HER2+ breast cancer (BC) patients (pts). Safety and efficacy of T in elderly patients are largely unknown. In HERA trial, NSABP B-31, NCCTG N9831 only 16% of pts were older than 60 years. Risk factors for T related cardiotoxicity are age (>50 y/o), hypertension, baseline LVEF (left ventricular ejection fraction <55%), previous antracycline therapy and BMI.

Methods: Charts of pts >65 y/o with early HER2+ BC treated with T as adjuvant or neoadjuvant therapy at our institution were retrospectively reviewed. Primary endpoint was the evaluation of T cardiac toxicity and safety.

Results: 22 elderly out of 172 pts (12%) were identified: 19 pts were treated only with surgery and adjuvant chemotherapy with concomitant or sequential T, 3 more pts also received neoadjuvant chemotherapy concomitant with T. According to Balducci’s criteria, fit, vulnerable and frail pts were 20, 2, 0 respectively. Median age was 69 y/o (range 65-76). Hormonal status was negative in 10/22 (45%). 21/22 were histologic grade 3. Median follow-up was 33 months. Baseline comorbidities were the following: hypertension (G2-3) in 17 pts, diabetes mellitus in 1, supra/infraventricular arrhythmia (G1-2) in 3 and 1 pts. Antracyclines were administered in 16 pts (liposomal-doxorubicin in 5 pts), a sequential taxane-regimen was used in 3 more pts. Neoadjuvant weekly Paclitaxel and concomitant T was used in 3 pts. Median basal LVEF was 65% (range 59-74%). 2 pts developed an asymptomatic 10% LVEF drop from baseline (left ventricular systolic dysfunction G1) during T treatment. Known cardiac risk factors were hypertension in 1 pt and previous antracycline based chemotherapy in both. They recovered within 9 months. One minor adverse event was atrial fibrillation (G2) during T treatment.

Conclusions: T was well tolerated in elderly pts. More data are needed in order to understand the correlations between T related toxicity and cardiovascular risk factors. Long term safety of T treatment should verify the reversibility of cardiac T related toxicity on elderly pts.

Early and short-term acenocumarine or dalteparin for the prevention of central vein catheter-related thrombosis in cancer patients: a randomized controlled study based on serial venographies

BACKGROUND

We evaluated efficacy and safety of early and short-term prophylaxis with acenocumarine or dalteparin in the prevention of non-occlusive or occlusive central vein catheter-related thrombosis (CVCrT).

PATIENTS AND METHODS

Consecutive cancer patients scheduled for chemotherapy randomly received: acenocumarine 1 mg/day for 3 days before and 8 days after central vein catheter (CVC) insertion; dalteparin 5000 IU 2 h before and daily for 8 days after CVC insertion; no anticoagulant treatment (NT). All patients underwent venography on days 8 and 30, some of them on days 90, 150 and 210 after CVC.

RESULTS

A total of 450 patients were randomized, 348 underwent at least two venography. Both acenocumarine and dalteparin reduced venography-detected CVCrT rate [21.9% acenocumarine versus 52.6% NT, odds ratio (OR) 0.3, P < 0.01; 40% dalteparin versus 52.6% NT, OR 0.6, P = 0.05]. Acenocumarine was more effective than dalteparin (OR 0.4, P = 0.01). The rate of occlusive CVCrT was not different in the three groups (0.9% acenocumarine, 3.3% dalteparin, 1.8% NT; P = 0.40). Most CVCrTs (95.6%) were observed on day 8 after CVC insertion and were non-occlusive.

CONCLUSIONS

In this study of early and short-term prophylaxis, acenocumarine was more effective than dalteparin on non-occlusive and asymptomatic CVCrT events. The first days following CVC insertion represent the highest risk for CVCrT.

Thymidine phosphorylase expression is associated with time to progression in patients receiving low-dose, docetaxel-modulated capecitabine for metastatic breast cancer

BACKGROUND

Preclinical data have indicated a synergistic interaction between docetaxel and capecitabine by means of taxane-induced up-regulation of thymidine phosphorylase (TP). On the basis of such premises, we conducted a phase II trial to determine the activity and tolerability of weekly docetaxel plus capecitabine in patients with metastatic breast cancer (MBC). Furthermore, we explored the relationship between TP tumor expression and benefit from this regimen.

PATIENTS AND METHODS

Patients received docetaxel 36 mg/m(2) i.v. on days 1, 8, and 15 and capecitabine orally 625 mg/m(2) b.i.d. from days 8 to 21. Cycles were repeated every 4 weeks. In the correlative study, we evaluated the TP expression by immunohistochemistry and the TP messenger RNA expression by real-time RT-PCR in the primary tumor.

RESULTS

Forty-seven women were enrolled. In the intention-to-treat analysis, objective responses were achieved in 24 patients (51%). Fourteen additional patients (30%) had stable disease. The median time to progression (TTP) was 6 months (range 1-44 months). Median survival was 17 months (range 1-48 months). Overall, the treatment was well tolerated. The most common clinical adverse events (all grades) were alopecia (55%), nail changes (53%), fatigue/asthenia (51%), nausea/vomiting (51%), neutropenia (49%), and neuropathy (49%). A significantly higher TTP was observed in patients with TP-positive tumors (log-rank test, P = 0.009). Interestingly, a subgroup analysis confirmed this TTP benefit in patients with TP-positive tumors obtaining a tumor response (log-rank test, P = 0.03), whereas the statistical significance was lost in nonresponders (log-rank test, P = 0.3).

CONCLUSIONS

This study indicates that a regimen with low doses of capecitabine plus weekly docetaxel is active against MBC. The correlative analysis provides preliminary evidence that TP expression may be a predictive marker for therapeutic benefit.

Treatment of liver toxicity in women undergoing adjuvant chemotherapy for breast cancer: A phase III, monocentric, prospective, randomised trial of ursodeoxycolic acid (UDCA) vs no treatment

9060

Background: Liver toxicity during adjuvant chemotherapy (CT) represents one of the causes of treatment delay and dose reduction, with impairment of dose intensity and of final results. UDCA, a hydrophilic bile acid, has been reported to be effective in cholestasis. Aim: to evaluate the efficacy of UDCA (12 mg/kg/die) plus CT discontinuation vs CT discontinuation alone in the treatment of liver toxicity. Methods: The study provided two arms of randomization: discontinuation of CT and administration of UDCA at the dosage of 12 mg/kg/day or discontinuation of CT. CT was resumed at normalization of liver tests. Pts with liver metastases, acute or chronic hepatopathy, heart or kidney failure, or PS<70 were excluded. During a 3 year period, 118/305 pts developed CT-induced hepatotoxicity and were enrolled into the study. Logistic multiple models and Fisher test or χ2 test and the Mann-Whitney test were used. Results: Out the 118 pts, 66% were treated with CMF, 29% with Anthracyclines alone or in sequence with CMF and 5% with Anthracyclines and Taxanes. Liver toxicity occurred respectively in 37 pts after the 1st cycle, in 35 after the 2nd, in 15 after the 3rd, in 19 after the 4th, in 9 after the 5th and in 3 after the 6th. CT was definitely stopped in 8% of pts. CT was delayed of 1 week in 53%, of 2 wks in 31% and of 3 or more in 16%. 95% of pts had a hepatocytolitic damage and nobody purely cholestatic. G1 toxicity was observed in 34%, G2 in 57%, G3 in 9%. Pts were randomized in two groups of 59 pts each. UDCA group: 3 pts (5%) stopped CT and 11 (19%) had dose reduction. Control group: 6 pts (10%) stopped CT and 7 (12%) had dose reduction. No statistically significant difference between UDCA group and control group was noted both for dose reduction (p = 0.31) and for CT stop (p = 0.30), even if twice as many pts of the control group had to stop CT (6/59). No correlation between alcohol use and liver damage was noted. Conclusions: Most cases of liver toxicity are of low or intermediate grade. No statistically significant difference was found between UDCA and control, even if there was a positive trend in reducing liver toxicity, that can have a positive impact on the final results of adjuvant CT.

No significant financial relationships to disclose.

Intraoperative radiotherapy (IORT) impairs surgical wound-stimulated breast cancer cell invasion

21139

Background: Risk of local recurrence after complete excision of breast cancer is higher in the area around the original tumor, suggesting that wound healing may be implicated. Methods: We collected blood samples (BS) before surgery and wound fluid (WF) in the 24 hours after breast conserving surgery from 50 patients. Twenty five of these patients were also treated with TARGeted Intraoperative radioTherapy (TARGIT, 20Gy to tumor bed surface in one session), immediately after the surgical excision. The ability of the BS and WF to stimulate growth and motility of a panel of normal and mammary carcinoma cells was studied. A proteomic approach was used to analyze the expression pattern of WF and BS. Results: We assayed five cell lines in a transwell based assay using individual patient BS and wound fluids WF as potential chemo-attractants. WF strongly attracted cells from all 5 types of breast cancer cell lines that we tested including MDA- MB 231, MCF-7, MDA-MB 453, T47D and SKBR-3. The WF attracted the cells better than both the respective BS. Importantly, in all tested cell lines TARGIT significantly impaired the ability of WF to attract cancer cells (p=0.03 MDA-MB 231 and MCF-7. p=0.01 for MDA-MB 453, and SKBR-3). Moreover, while BS did not stimulate 3D motility over the control WF strongly stimulated 3D movement of MDA-MB 231 and MDA-MB- 453 cells. This stimulatory effect was abrogated in the WF taken from patients who had received TARGIT (p=0.01 for MDA-MB 231 and p<0.0001 for MDA-MB 453). Similar results were obtained when cell proliferation was evaluated using the same cell lines and BS or WF samples. Finally, proteomics analyses demonstrated that TARGIT modifies the expression levels of several key proteins involved in tumor cell growth and dissemination. Conclusion: TARGIT delivered to the tumor bed alters the cytokines and growth factors expression patterns in the surgical wound and abrogates its stimulatory effect on cancer cell growth and motility. This novel mechanism of action of radiotherapy could partly explain the very low recurrence rates found in large pilot studies of this technique and open new avenues for peri-operative therapies.

No significant financial relationships to disclose.

Oral etoposide in elderly patients with advanced non small cell lung cancer: a clinical and pharmacological study

Seventeen elderly patients with advanced progressive non small cell lung cancer (NSCLC) were treated with oral etoposide at the daily dose of 100 mg for 14 days every 3-4 weeks with pharmacokinetic monitoring. One partial response and 6 stabilizations were documented with a median overall duration of 13 weeks (range 8-32). The median survival was 24 weeks with an apparent advantage for non-progressive patients (40 weeks vs. 18 weeks). The treatment was well tolerated especially by those patients without concomitant illness, suggesting the crucial role of a careful selection of the geriatric population. Toxicity was not related to the etoposide plasma level, but was clearly dependent on comorbidity. A geriatric assessment rather than chronological age therefore appears to be more reliable in the selection of elderly patients for clinical trials. The easy self-management, favorable toxicity profile and synergy with other compounds makes oral etoposide suitable for further clinical-pharmacological studies in elderly patients.

Short-term acenocumarine (A) or dalteparine (D) for the prevention of central venous catheter-related thrombosis (CVCrT) in cancer patients. A randomized controlled study based on serial venographies

8549

Background: Timing and frequency of non occlusive (nO) or occlusive (O) CVCrT in cancer patients (pts) remain unclear. In this randomized controlled trial we studied these points and evaluated the efficacy and safety of short-term prophylaxis with A or D in the prevention of CVCrT. Methods: Consecutive cancer pts without contraindications to short-term anticoagulation, scheduled for chemotherapy via CVC, were randomly assigned to receive: A 1 mg/day for 3 days before and 8 days after CVC insertion; D 5,000 IU 2 hours before and daily for 8 days after CVC insertion; no anticoagulant treatment (NT). All pts underwent venography (V) at day 8 and 30 after CVC insertion and then every two months until CVC removal . The primary endpoint was V detected CVCrT, evaluated as nO or O when it was partially or completely occlusive of the vein lumen, respectively. Bleeding episodes were recorded. Proportions were compared using chi-square test together with odds ratio (OR). Results: 450 pts were randomized, 348 of whom (120/150 A, 114/150 D, and 114/150 NT) underwent V (median number of procedures 4, range 2–8). Both A and D reduced the frequency of V detected CVCrT (21.9% A vs 55.3% NT, OR= 4.35 (95% CI 2.43–7.69), p<0.001; 40% D vs 55.3% NT, OR= 1.85 (95% CI 1.10–3.13), p=0.02). A was more effective than D (OR= 2.37 (CI 1.34–4.22), p= 0.003). The frequency of O CVCrT was not different in the 3 groups (0.9% A, 5.0% D, 4.4% NT; p= 0.18). Overall, 5.1% of pts with CVCrT were symptomatic, all presenting O CVCrT (42% of pts with O CVCrT were not symptomatic). Most CVCrTs (95.6%) were observed at day 8 after CVC insertion. No major bleeding or pulmonary embolism occurred. Conclusions: In this study, acenocumarine was more effective than dalteparine in reducing V detected CVCrT. The doses of prophylactic agents used in this study proved to be safe. Symptomatic CVCrT evaluation alone underestimates the actual CVCrT frequency. The first days following CVC insertion are at highest risk for CVCrT. Short term thrombosis prophylaxis appears to be superior to no treatment without the expenses and inconveniences inherent in long-term prophylaxis.

No significant financial relationships to disclose.

Innovative schedule of oral idarubicin in elderly patients with metastatic breast cancer: comprehensive results of a phase II multi-institutional study with pharmacokinetic drug monitoring

BACKGROUND

To determine if protracted low-dose oral idarubicin (IDA), feasible in a previous dose-finding study, would result in similar activity and a better toxicity profile in patients with metastatic breast cancer.

PATIENTS AND METHODS

Elderly women (> or=65 years) with metastatic breast carcinoma were treated with 7.5 mg/day for 21 consecutive days, every 4 weeks. After the first fourteen patients, due to excessive toxicity, the protocol was amended to 5 mg/day. IDA and Idarubicinol (IDOL) plasma concentrations (C(trough)) were investigated in all patients.

RESULTS

Between April 1999 and June 2004, 47 elderly patients were accrued in this two-part study (14 and 33 patients respectively). The median age was 74 and 75 years respectively. Visceral involvement was present in most patients. A partial response was noted in 7/31 patients (22%; 95% CI, 9.6-41.1%). Eleven patients had stable disease (33%). At the dose of 5 mg/day the treatment was well tolerated. Neutropenia grade 4 was present in only 6% of patients; alopecia > grade 1 and cardiotoxicity did not occur. The median time to progression was 3 months and the median overall survival was 17 months. IDA C(trough) and IDOL C(trough) levels were significantly associated with haematologic toxicity.

CONCLUSION

This study shows that idarubicin at the dose of 5 mg/day for 21 consecutive days is feasible and effective in elderly breast cancer patients but do not demonstrate an improvement in efficacy. A determination of the IDA and IDOL plasma levels (C(trough)) is predictive for toxicity.

Timing of CMF chemotherapy in combination with tamoxifen in postmenopausal women with breast cancer: role of endocrine responsiveness of the tumor

BACKGROUND

Controversy persists about whether chemotherapy benefits all breast cancer patients.

PATIENTS AND METHODS

In the International Breast Cancer Study Group (IBCSG) trial VII, 1212 postmenopausal patients with node-positive disease were randomized to receive tamoxifen for 5 years or tamoxifen plus three concurrent courses of cyclophosphamide, methotrexate and 5-fluorouracil ('classical' CMF) chemotherapy, either early, delayed or both. In IBCSG trial IX, 1669 postmenopausal patients with node-negative disease were randomized to receive either tamoxifen alone or three courses of adjuvant classical CMF prior to tamoxifen. Results were assessed according to estrogen receptor (ER) content of the primary tumor.

RESULTS

For patients with node-positive, ER-positive disease, adding CMF either early, delayed or both reduced the risk of relapse by 21% (P=0.06), 26% (P=0.02) and 25% (P=0.02), respectively, compared with tamoxifen alone. There was no difference in disease-free survival when CMF was given prior to tamoxifen in patients with node-negative, ER-positive tumors.

CONCLUSIONS

CMF given concurrently (early, delayed or both) with tamoxifen was more effective than tamoxifen alone for patients with node-positive, endocrine-responsive breast cancer, supporting late administration of chemotherapy even after commencement of tamoxifen. In contrast, sequential CMF and tamoxifen for patients with node-negative, endocrine-responsive disease was ineffective.

Quantifying trade-offs: quality of life and quality-adjusted survival in a randomised trial of chemotherapy in postmenopausal patients with lymph node-negative breast cancer

We evaluated quality of life (QL) and quality-adjusted survival in International Breast Cancer Study Group Trial IX, a randomised trial including 1669 eligible patients receiving tamoxifen for 5 years or three prior cycles of cyclophosphamide, methotrexate and 5-fluorouracil (CMF) followed by 57 months tamoxifen. During the time with CMF toxicity (Tox), without symptoms and toxicity (TWiST), and following relapse (Rel), patients scored their QL indicators and a utility indicator for subjective health estimation between ‘perfect’ and ‘worst’ health. Scores were averaged within Tox, TWiST and Rel and transformed to utilities. Mean durations for the three transition times were weighted with utilities to obtain mean quality-adjusted TWiST (Q-TWiST). Patients receiving CMF reported significantly worse scores for most QL domains at month 3, but less hot flushes. After completing chemotherapy, there were no differences by treatment groups. Benefits evaluated by Q-TWiST favoured the additional chemotherapy. CMF provided 3 more months of Q-TWiST for patients with ER-negative tumours, but CMF provided no benefit in Q-TWiST for patients with ER-positive tumours. Q-TWiST analysis based on patient ratings is feasible in large-scale cross-cultural clinical trials.

Amelanotic/hypomelanotic melanoma: clinical and dermoscopic features

BACKGROUND

Amelanotic malignant melanoma is a subtype of cutaneous melanoma with little or no pigment on visual inspection. It may mimic benign and malignant variants of both melanocytic and nonmelanocytic lesions.

OBJECTIVES

To evaluate whether dermoscopy is also a useful technique for the diagnosis of amelanotic/hypomelanotic melanoma (AHM).

METHODS

We conducted a retrospective clinical study of 151 amelanotic/hypomelanotic skin lesions from 151 patients with a mean age of 47 years (+/- 17.5 SD). Digitized images of amelanotic/hypomelanotic skin lesions were converted to JPEG format and sent by e-mail from the five participating centres. Lesions included 55 amelanotic/hypomelanotic nonmelanocytic lesions (AHNML), 52 amelanotic/hypomelanotic benign melanocytic lesions (AHBML), and 44 AHM, 10 (23%) of which were nonpigmented, truly amelanotic melanomas (AM). The 44 AHM lesions were divided into thin melanomas (TnM) </= 1 mm (29 cases) and thick melanomas (TkM) > 1 mm (15 cases), according to the Breslow index. Five clinical features (elevation, ulceration, shape, borders and colour) as well as 10 dermoscopic criteria (pigment network, pigmentation, streaks, dots/globules, blue-whitish veil, regression structures, hypopigmentation, leaf-like areas, multiple grey-bluish globules, central white patch) and eight vascular patterns (comma, arborizing, hairpin, dotted, linear irregular, dotted and linear irregular vessels, and milky-red areas) were evaluated in order to achieve clinical and dermoscopic diagnoses. Statistical analyses were performed with the chi2-test and Fisher's exact test, when appropriate.

RESULTS

The most frequent and significant clinical features for TnM and TkM were asymmetry and ulceration (the latter only for TkM) compared with AHBML. Irregular dots/globules (62% vs. 35%; P </= 0.03), regression structures (48% vs. 27%; P </= 0.03), irregular pigmentation (41% vs. 11%; P </= 0.03) and blue-whitish veil (10% vs. 0%; P </= 0.03) were the most relevant dermoscopic criteria for TnM in comparison with AHBML. TkM differed significantly from AHBML in frequency of occurrence of irregular pigmentation (87% vs. 11%; P </= 0.03), irregular dots/globules (73% vs. 35%; P </= 0.03), regression structures (67% vs. 27%; P </= 0.03), blue-whitish veil (27% vs. 0%; P </= 0.03) and hypopigmentation (13% vs. 55%; P </= 0.03). Linear irregular vessels and the combination of dotted and linear irregular vessels associated with TnM and TkM were not found in our cases of AHBML and were only rarely seen in AHNML (3.6% and 1.8%, respectively). Moreover, TkM differed significantly from AHBML and TnM in frequency of occurrence of milky-red areas (93% vs. 17%; P </= 0.03 and 93% vs. 31%; P </= 0.01, respectively). The dermoscopic diagnosis of melanoma had a higher sensitivity and specificity than the clinical diagnosis (89% and 96% vs. 65% and 88%, respectively). With the limitation of the small number of cases, vascular patterns were the only dermoscopic criteria for 'truly' AM. In the 10 cases of 'truly' AM, we found milky-red areas in more than half of the cases (six of 10), dotted vessels in four, hairpin vessels in two, linear irregular vessels in two, dotted and linear irregular vessels in two.

CONCLUSIONS

Because dermoscopy uses criteria reflecting pigmentation (irregular pigmentation and irregular dots/globules) and vascular patterns, it is a useful technique not only for pigmented melanoma but also for hypomelanotic melanoma. In 'truly' AM, vascular patterns alone may not be sufficient to diagnose melanoma. A combined approach with the clinical information should help in the detection of 'truly' AM.

Ifosfamide in Advanced/Disseminated Breast Cancer

Ifosfamide is an alkylating agent active in various tumor types including breast cancer. The availability of mesna (sodium 2-mercaptoethanesulfonate) has increased its safety, avoiding the main dose-limiting side effect, urotoxicity. Interesting activity as a single agent, with response rates ranging from 7 to 30%, is reported in pretreated patients; more attractive data derived from phase II studies on ifosfamide combined with drugs known to be active in advanced breast cancer show response rates always over 35%. This review has taken in consideration papers published after 1995 and available on PubMed medline: the data indicate a potential usefulness of ifosfamide in the clinical management of advanced breast cancer, even if the exact therapeutic role of the drug in this setting should be derived from randomized studies not yet available.

Adjuvant systemic therapies in women with breast cancer: an audit of clinical practice in Italy

BACKGROUND

Evidence-based guidelines, consensus conferences and experts' opinion are rarely promptly transferred to patient care. We audited prescriptions of adjuvant systemic therapies for Italian breast cancer patients and compared them with recommendations of an International Consensus Panel.

PATIENTS AND METHODS

Disease characteristics and adjuvant therapies for 768 breast cancer patients referred to 87 Italian centers from 16 to 23 March 2000 were evaluated for adherence to the published recommendations.

RESULTS

Endocrine therapy was not prescribed for 102 of 541 patients (19%) with endocrine-responsive disease and for 22 of 45 patients (49%) with unknown hormonal receptor status. Instead, endocrine therapy was prescribed for 22 of 182 patients (12%) with endocrine-unresponsive disease. Adjuvant chemotherapy was prescribed for 98% of the patients. The type of chemotherapy was the cyclophosphamide, methotrexate, 5-fluorouracil regimen for 453 of 754 (60%), while 253 of 754 (34%) received an anthracycline-based regimen. The proportion of patients with anthracyclines increased with the number of involved axillary nodes and grading, and decreased with age. Endocrine therapy was administered to 482 of 768 (63%) and was mainly represented by an antiestrogen.

CONCLUSIONS

Lack of adherence to evidence-based guidelines for adjuvant treatment of Italian breast cancer patients was as high as 19%. It might be wise for national health authorities to promote education on life-saving procedures, like adjuvant systemic treatments, in cancer medicine.

Treatment of older breast cancer patients with high recurrence risk

Adjuvant treatment of elderly women affected by breast cancer who have a high risk of recurrence is one of the most questionable issues in clinical oncology. The use of tamoxifen in women with hormone receptor-positive tumors is a relatively simple therapeutic option considering the favourable toxicity profile, whereas the administration of adjuvant chemotherapy is more complicated and a variety of aspects need to be considered. The estimated life expectancy, the presence and degree of comorbid conditions, the geriatric assessment and estimated benefit from treatment should be taken into account. Due to the lack of data from clinical trials in women over the age of 70, the approach is still experimental. Clinical trials evaluating the role of adjuvant chemotherapy in high risk patients are currently being developed and hopefully in the near future, more convincing data on the best drugs, regimens and benefits for the treatment of elderly breast cancer patients will become available.

The Italian multi-centre project on evaluation of MRI and other imaging modalities in early detection of breast cancer in subjects at high genetic risk

This report presents the preliminary results of the first phase (21 months) of a multi-centre, non-randomised, prospective study, aimed at evaluating the effectiveness of contrast-enhanced magnetic resonance imaging (MRI), X-ray mammography (XM) and ultrasound (US) in early diagnosis of breast cancer (BC) in subjects at high genetic risk. This Italian national trial (coordinated by the Istituto Superiore di Sanità, Rome) so far recruited 105 women (mean age 46.0 years; median age 51.0; age range 25-77 years), who were either proven BRCA1 or BRCA2 mutation carriers or had a 1 in 2 probability of being carriers (40/105 with a previous personal history of BC). Eight cases of breast carcinomas were detected in the trial (mean age 55.3 years, median age 52.5; age range 35-70 years; five with previous personal history of BC). All trial-detected BC cases (8/8) were identified by MRI, while XM and US correctly classified only one. MRI had one false positive case, XM and US none. Seven "MRI-only" detected cancers (4 invasive, 3 in situ) occurred in both pre- (n = 2) and post-menopausal (n = 5) women. With respect to the current XM screening programmes addressed to women in the age range 50-69 years, the global incidence of BC in the trial (7.6%) was over ten-fold higher. The cost per "MRI-only" detected cancer in this particular category of subjects at high genetic risk was substantially lower than that of an XM-detected cancer in the general women population. These preliminary results confirmed that MRI is a very useful tool to screen subjects at high genetic risk for breast carcinoma, not only in pre-, but also in post-menopausal age, with a low probability of false positive cases.

Neopterin production in SCID mice injected with human peripheral blood mononuclear cells

Intraperitoneal transfer of peripheral blood mononuclear cells (PBMC) from human EBV+ donors into severe combined immunodeficiency (SCID) mice is a suitable model for studying some aspects of lymphomagenesis and immune activation. Neopterin is a soluble immune marker which was found to be a useful indicator for immune activation processes in humans, e.g. to monitor immunological complications in allograft recipients or to predict prognosis in HIV-infected individuals. In contrast, this pteridine compound is normally synthesized in murine organism in only very low amounts. The measurement of neopterin concentrations in serum and urine should be feasible in SCID mice reconstituted with human PBMC. In this study, we examined the usability of this experimental model for monitoring human T cell activation by neopterin measurements. The production of neopterin by SCID mice after injection of freshly isolated human PBMC, purified B or T cells and cultured Epstein-Barr virus (EBV)+ lymphoblastoid cells (LCL) was determined. It was found that neopterin can be detected early after injecting SCID mice with PBMC, whereas injection of purified human T or B cells did not result in neopterin production. Highest neopterin levels were detected in mice treated with LCL cells when developing lymphoma. We discuss the possible sources of neopterin along this process and its usefulness in this model.

Reconstruction of the retroauricular fold: a personal technique

In auricular reconstruction emphasis is placed on carving the rib-cartilage framework. The three-dimensional frame is very important in obtaining a good anatomical shape but often a good shape is not complemented by a good projection of the auricle. In order to avoid obliteration of the retroauricular fold we use a cartilage wedge covered by a local fascial flap. We have treated 17 ears in 16 patients with this technique and have obtained satisfactory results in all cases, achieving a mean projection of 1.7cm between the mastoid plane and the helical rim.

High incidence of central nervous system involvement in patients with metastatic or locally advanced breast cancer treated with epirubicin and docetaxel

BACKGROUND

Clinically overt central nervous system (CNS) involvement occurs in 10%-15% of patients with advanced breast cancer.

PATIENTS AND METHODS

The International Breast Cancer Study Group (IBCSG) conducted a dose-finding phase I trial of epirubicin (E) and docetaxel (D) as first-line therapy in advanced breast cancer patients. The study was expanded into a phase II at the recommended doses of E 90 mg/m2 and D 75 mg/m2 every three weeks. From July 1996 to May 1998, a total of 92 patients (median age 50 years) entered the two studies.

RESULTS

Twenty-eight out of ninety-two patients treated with the combination of E and D (30%) developed CNS metastases (95% confidence limits, 26%-35%), which were cerebral in twenty-five patients, leptomeningeal in two, and both in one. Of these 28 patients, 19 (68%) had an objective response. Median time for the development of CNS metastases from the start of chemotherapy was 15 months (range 5-42), if excluding the 6 patients presenting CNS progression within 3 months from start of treatment. It is notable that 11 patients (39%) had progression in the CNS only. Median survival from appearance of brain metastases in the whole group was only three months (range 1-22). C-erbB-2 overexpression was found in 14 out of 16 patients (87%) in whom the assay was performed (3+ in 10, 2+ in 1 and 1+ in 3 cases).

CONCLUSIONS

As anthracycline- and taxane-containing regimens are increasingly used both in the metastatic and in the adjuvant setting, a careful monitoring of any neurological symptom is advisable. Our preliminary observation on the possible increase of incidence of CNS involvement in patients with advanced breast cancer receiving this effective drug combination requires further evaluation.

Dermoscopic criteria for melanoma in situ are similar to those for early invasive melanoma

BACKGROUND

Dermoscopy is a noninvasive technique that increases the diagnostic accuracy of pigmented skin lesions, particularly improving the diagnosis of patients with cutaneous melanoma in situ (CMIS) and early invasive melanoma. To establish reliable and reproducible dermoscopic criteria for the diagnosis of CMIS, the authors conducted a retrospective clinical study of 37 patients with CMIS and 53 patients with invasive cutaneous melanomas (ICM).

METHODS

The 37 patients with CMIS were divided into three groups: those with CMIS lesions measuring < or = 5 mm in greatest dimension (8 patients), those with CMIS lesions measuring from > 5 mm to < or = 10 mm in greatest dimension (20 patients), and those with CMIS lesions measuring > 10 mm in greatest dimension (9 patients). The 53 patients with ICM were divided into two groups according to Breslow index: those with ICM lesions measuring < or = 0.75 mm in tumor thickness (19 patients) and those with ICM lesions measuring > 0.75 mm in tumor thickness (34 patients). Lesions were examined with a dermatoscope and were photographed at a magnification of x10. Dermoscopic criteria were evaluated from examination of the photomicrographs.

RESULTS

Blue-whitish veil, gray-blue areas, black dots, and irregular extensions and branched streaks were the most relevant dermoscopic criteria for CMIS and were present in 78%, 76%, 73%, and 62% of lesions, respectively. Brown globules, irregular pigment network, pseudopods, and depigmentation were present in 57%, 54%, 54%, and 51% of CMIS lesions, respectively. White scar-like areas and linear and/or dotted vascular patterns, two criteria that are associated frequently with ICM, were not found in our patients with CMIS. No clinically significant differences were observed between the three groups of CMIS patients.

CONCLUSIONS

Dermoscopic criteria for CMIS were similar to those for ICM, although white scar-like areas and linear and/or dotted vascular patterns were observed only in patients with ICM. Dermoscopic criteria appeared to be independent of CMIS lesions size.

Elderly ovarian cancer: treatment with mitoxantrone-carboplatin

OBJECTIVE

Data concerning optimal treatment of elderly patients with ovarian cancer are scanty. The management of ovarian cancer in the aged patient is many-sided: the diagnosis can be difficult and delayed, and aggressive surgery is often not attempted because of concomitant morbidity. We tested a combination of carboplatin and mitoxantrone potentially associated with low toxicity in elderly patients with ovarian cancer.

METHODS

Eighty-two patients older than 70 years (median age, 75; range, 70-88) with epithelial ovarian cancer were referred to our multicenter group and enrolled into this pilot study. Carboplatin (JM8) was given at the dose of 230 mg/m2 and mitoxantrone at the dose of 9 mg/m2 every 28 days.

RESULTS

Dose-limiting toxicity was represented by 4 cases of thrombocytopenia and 1 case of gastrointestinal toxicity. These 5 episodes occurred in 328 assessable cycles, representing a low toxicity profile (3%). Of the 68 assessable patients, 36 (53%) did not respond to chemotherapy (no change + progressive disease), complete response was observed in 15 (22%), and partial remission was observed in 16 (23.5%), accounting for an overall response rate of 45%.

CONCLUSION

The carboplatin-mitoxantrone combination, at the dosage tested in this study, appears to be well tolerated by elderly patients with advanced ovarian cancer and is associated with an acceptable response rate. Optimally debulked patients also showed improved survival when compared with patients with more extensive tumor.

Identifying breast cancer patients at high risk for bone metastases

PURPOSE

To identify patient populations at high risk for bone metastases at any time after diagnosis of operable breast cancer, because these patients are potential beneficiaries of treatment with bisphosphonates.

PATIENTS AND METHODS

We evaluated data from 6,792 patients who were randomized in International Breast Cancer Study Group clinical trials between 1978 and 1993. Median follow-up was 10. 7 years. A total of 1,275 patients (18.7%) presented with node-negative disease, whereas 3,354 patients (49.4%) had one to three and 2,163 patients (31.9%) had four or more involved axillary lymph nodes. We also assessed the incidence of subsequent bone metastases in the cohort of 1,220 patients who had a first event in local or regional sites or soft tissue alone. Median follow-up for this cohort was 7.7 years from first recurrence.

RESULTS

For the entire population with operable disease, the cumulative incidence of bone metastases at any time was 8.2% at 2 years from randomization and 27.3% at 10 years. The highest cumulative incidences of bone metastases at any time were among patients who had four or more involved axillary nodes at the time of diagnosis (14.9% at 2 years and 40.8% at 10 years) and among patients who had as their first event a local or regional recurrence or a recurrence in soft tissue, without any other overt metastases (21.1% at 2 years from first recurrence and 36.7% at 10 years).

CONCLUSION

Treatments to prevent bone metastases may have a major impact on the course of breast cancer and may be most efficiently studied in populations with several involved axillary nodes at the time of presentation and in populations with local or regional recurrence or recurrence in soft tissue.

Determination of tamoxifen and its metabolites in the endometrial tissue of long-term treated women

Concentrations of tamoxifen and its metabolites were analysed in the endometrium of 23 post-menopausal asymptomatic breast cancer patients who were on chronic tamoxifen therapy. Small endometrial samples were collected during diagnostic hysteroscopy. Analysis of both serum and tissue for these compounds was performed by mass spectrometry. Tamoxifen and its metabolites were far more concentrated in the endometrium than in serum; tamoxifen was also significantly more concentrated in endometrium with hyperplastic changes than in atrophic endometrium. Endometrial polyps of an additional 9 women showed a trend to a lesser concentration of compounds. Increased concentration of tamoxifen compounds could possibly be explained by the avidity of these compounds for oestrogen receptors (ER).