Chromogranin-A Expression in Neoplastic Neuroendocrine Cells and Prognosis in Colorectal Cancer

Aims

Chromogranin-A (CG), a cytoplasmic glycoprotein, is one of the markers most frequently used to identify the presence of neuroendocrine cells in the human gastrointestinal tract. Several authors have identified a subgroup of colorectal cancer patients with a severe prognosis whose tumors contained neuroendocrine CG-positive cells. In the present study, CG expression in 100 patients with colorectal adenocarcinoma treated from January 1983 to December 1988 with potentially curative surgery was analyzed and correlated with other prognostic factors and 5-year survival rate.

Methods

Samples tested immunohistochemically for CG were divided into three groups: I) negative; II) less than 1 CG-positive cell/mm2; III) more than 1 CG-positive cell/mm2.

Results

Of 100 patients with primary colorectal adenocarcinoma, 79% had tumors comprised of CG-negative cells, 17% had rare CG-positive cells, and 4% of cases could be classified in group III. No significant relation between CG expression and location of primary tumor, bowel wall infiltration, stage of disease or tumor grade according to Broders and Jass was observed. The 5-year survival was 53% and 52% for CG-positive and CG-negative lesions, respectively. Survival of patients with Dukes-Kirklin stage C and D was comparable in patients with CG-positive (33.3%) and CG-negative (30%) tumors.

Conclusions

CG expression cannot, at present, be recommended as a marker to identify prognostic subgroups in colorectal cancer patients.

Hematologic Parameters during Treatment with High-Dose Medroxyprogesterone Acetate

Blood clotting, platelet aggregation, complete blood count and lipid profile were evaluated in 12 postmenopausal patients with advanced breast cancer. Patients under treatment with high-dose MPA were considered not at risk for thomboembolic disease and were given MPA orally, 800 mg/day, for at least 3 months. Laboratory investigations were performed prior to treatment with MPA then once weekly during the first month and every 2 weeks during the following months. PTT, TEG, antithrombin III and platelet adhesiveness underwent statistically significant changes, tending towards hypercoagulability, although, on the average, they did not exceed the upper normal range. The authors conclude that a clinically relevant thrombotic activity cannot be attributed to MPA at the administered oral doses in the absence of additional risk factors.

Grading as a Prognostic Factor: Review of 209 Primary Gastric Cancer Patients

Two hundred and nine cases of primary gastric cancer were treated surgically from January 1968 to December 1983 and analyzed retrospectively. All patients were followed up for a minimum of 5 years. There were 25 SI cases (12 %), 22 SII (10.5%), 55 SIII (26.3%) and 107 SIV (51.2%). Tumor grade according to Broders classification showed 50 cases of G1 lesions (23.9%), 44 G2 (21.1 %) and 115 G3 (55%). Patients with well differentiated G1 lesion, compared to G2-G3 patients, presented a greater incidence of T1-T2 tumors and decreased incidence of T4 tumors (p < 0.05). The lymph node involvement rate significantly increased with variation of T (p < 0.001) but not with tumor grade. Survival results correlated with tumor stage (p < 0.01) but not with tumor grade or histological type.

Epiglottic Non-Hodgkin's Lymphoma: Case Report

A locally recurrent head and neck nodal, B cell nodular, non-Hodgkin's lymphoma transformed to a diffuse histologic pattern with a peculiar bone marrow and epiglottic involvement without other apparent localizations is reported. Radiotherapy proved highly effective for local control of the epiglottic lesion but chemotherapy failed to eradicate bone marrow disease.

The Antiemetic Efficacy of Methylprednisolone Compared with Metoclopramide in Outpatients Receiving Adjuvant CMF Chemotherapy for Breast Cancer: A Randomized Trial

A randomized trial was performed comparing the antiemetic efficacy of methylprednisolone (MPN) and metoclopramide (MCP) in 60 breast cancer patients eligible for outpatient adjuvant chemotherapy with cyclophosphamide, methotrexate, and 5-FU (CMF). At the time of their first chemotherapy course patients were randomized to receive either MPN 375 mg or MCP 1 mg/kg both administered in 3 equal doses, IV just prior to chemotherapy and then IM 6 and 12 hours after treatment. Patients receiving MPN experienced significantly less nausea (p < 0.0005) and vomiting (p < 0.0005) and antiemetic protection was maintained in patients receiving multiple chemotherapy courses. Complete protection (0 emesis) was observed in 58 % of patients receiving MPN as compared with 20 % of patients treated with MCP (p < 0.005). The most frequent side effects were facial flush in 38 % of patients and somnolence in 15 % of patients receiving MPN and MCP, respectively. Complete protection from CMF-induced gastrointestinal side effects was observed in two-thirds of our patients receiving antiemetic MPN treatment. In these patients administration of the maximum cumulative CMF dose was possible without impairing their quality of life. MPN, at the dose and schedule reported, is an affective antiemetic drug suitable for use in breast cancer outpatients receiving adjuvant CMF therapy.

Management of pain in patients (PTS) receiving active therapy for cancer

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Background: The World Health Organization (WHO) estimates suggest that moderate to severe pain is experienced by one- third of pts receiving active therapy for their disease and by 60–90% of patients with advanced disease. Procedures that make pain assessment and effective management strategies a routine part of every patient care are recommended. The aim of this study was to integrate nursing intervention with physician management of cronic cancer pain experienced by pts receiving active therapy for cancer. Methods: An Oncology Nurse measured pain in all patients (universal screening) presenting at the Day Hospital for active therapy. Pain was measured using a validated instrument: the Visual Analog Scale (VAS). The pain intensity VAS scale is a 10 cm line anchored on either end by the terms least possible pain and worst possible pain. In addition. the Memorial Pain Assessment Care (MPAC) that consists of 3 VAS scales that measure pain intensity, pain relief and mood and a set of pain severity descriptors adapted from the Tursky rating scale was used. Results: From April 2004 to June 2006 a total of 704 pts were evaluated for pain, 334 (47%) males and 370 (53 %) females with median age 65 years (range 19–85). Results of pain measurement can be synthesized as follows: Pts with VAS = 4 were referred to the oncologist on the same day that pain was measured and analgesics were prescribed according to intensity and type of pain. Conclusions: Results indicate that pain can be universally evaluated and successfully managed in an Oncology Day Hospital. Assessment and treatment of cancer pain should be integrated into routine cancer care. Intervention by the oncology nursing staff is an integral part of effective cancer pain management.

No significant financial relationships to disclose.

[Table: see text]

Single-agent docetaxel (TXT) as first-line treatment in metastatic breast cancer (MBC)

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Background: Historically anthracyclines have been considered the most active agents in metastatic breast cancer (MBC). Docetaxel (TXT) has challenged this belief. Aims: Evaluate response rates, toxicity and time to progression in patients with MBC receiving single agent TXT as first line treatment. Methods: MBC patients received first line single agent treatment according to one of the following schedules: TXT 35 mg/m2 iv weekly for 6 wks q 8 wks (Group 1) or TXT 100 mg/m2 iv day 1 q 3 weeks (Group 2). Adjuvant chemotherapy was FAC (600,50,600) day 1 q 21 days for 6 courses in all cases so treated. Results: Conclusions: It appears that results with single agent TXT obtained in clinical practice are comparable to those reported in Phase II-III trials (Group 1 and Group 2, respectively ) using the same regimens.

[Table: see text]

No significant financial relationships to disclose.

Cancer patients as 'experts' in defining quality of life domains. A multicentre survey by the Italian Group for the Evaluation of Outcomes in Oncology (IGEO)

Although the subjective nature of quality of life is generally accepted, less attention has been paid to the procedure of selecting domains to be explored with questionnaires. To explore what contributes to cancer patients' quality of life, a survey was conducted with the aim of identifying contents of quality of life using cancer patients as 'experts'. A questionnaire with open-ended items aimed at exploring the meaning of quality of life and at determining the contents of health and not health related quality of life, was submitted to a sample of cancer patients stratified by residence, cancer site and stage of disease. The 248 questionnaires received were transcribed and broken down into phrases to allow coding. A content analysis was performed, using as a conceptual framework, the domains identified by the Italian Society of Psycho-Oncology. Overall, 43 domains and a list of symptoms were identified. The two most frequently reported symptoms were pain (21.4% patients) and fatigue (14.1% patients). Social relationships and psychological domains were heavily represented. Twenty sub-domains related to the domain 'psychological well-being'. This study suggests that information on the content of quality of life questionnaires to be submitted to people affected by a specific disease, should be derived by studying people suffering the specific disease. These results reinforce the criticism that available quality of life instruments are more likely to reflect the perspective of health professionals than patients.

Metastatic breast cancer patients failing first-line, anthracycline-containing chemotherapy: is further therapy of benefit?

During the last 50 years median survival for metastatic breast cancer has not varied and remains 2-3.5 years. To assess the clinical benefit of salvage systemic therapy a retrospective analysis of metastatic breast cancer patients all homogeneously treated with a commonly used first-line anthacycline-containing cytotoxic regimen (FEC) was undertaken. The 140 patients in this report were among 375 entered in two consecutive multicenter randomized trials carried out from Dec. 1983 to Jan. 1990. All patients died during follow-up. Median number of salvage therapies was 3 (range 1-7). Response rate (CR and PR) was 41% with FEC and 7%, 3%, 15%, 0%, 14%, 0%, 0% in patients receiving salvage treatment line 1 to 7, respectively. Time to treatment failure (TTF) was 7.5 months for FEC and 3.5, 2.5, 2.1, 1.6, 2.1, 1.1, 1.6 months at first to seventh salvage treatment, respectively. Only a very small fraction of patients receiving first-line FEC respond to subsequent palliative treatment. The advantages of salvage therapy are unclear and must be weighed against the inconvenience, cost and morbidity of treatment. After first salvage therapy, patients should be considered for randomized trials comparing systemic antineoplastic therapy with best palliative care. Endpoints of all future clinical trials in metastatic breast cancer should include measurement of quality of life and accurate, sequential measurement of symptom control.

Local control after curative surgery for cancer of the extraperitoneal rectum. Twenty years of experience

A retrospective study was carried out in 264 patients with low rectal cancer surgically treated with curative intent from January 1975 to December 1995 to analyze the influence of stapling devices on surgical and disease outcome. Patients were classified as follows: group 1 underwent surgery from 1975 to 1980, when staplers were not employed, and group 2 from 1981 to 1995, when stapling devices were routinely used. The use of stapling devices determined a corresponding increase in low anterior resection (LAR) and a decrease in postoperative mortality. A statistically significant difference in local recurrence rate between abdominoperineal resection (APR) patients and LAR sutured cases of group 1 was observed. In T3, N+ cases local recurrence rate was comparable in APR patients and LAR cases with stapled anastomosis. Improved local control occurred in stapled group 2 patients which was independent of the distal clearance. Although APR still plays an important role in treatment of lower rectal cancer, results indicated that a similar outcome after stapled LAR can also be expected in locally advanced carcinoma of the distal rectum, if accurate excision of perirectal tissue is carried out.

Factors influencing incidence and extension of metachronous liver metastases of colorectal adenocarcinoma. A multivariate analysis

BACKGROUND/AIM

Three hundred and eighty-seven patients surgically treated for colorectal adenocarcinoma were assessed by a multivariate analysis and the factors influencing incidence and extension of metachronous liver metastases studied.

METHODOLOGY

A series of 387 patients which had been surgically treated for colorectal adenocarcinoma between January 1980 to December 1990 and followed-up over a minimum of a 5-year period was retrospectively studied.

RESULTS

The most reliable prognostic markers are represented by tumor site (p < 0.05) and, more specifically, by wall infiltration (p < 0.01) and metastatic lymph-nodes (p < 0.05). The only independent variable with a significant impact on stage of metachronous liver metastases was proved to be the depth of wall infiltration (p < 0.05).

CONCLUSION

This study confirms the reliability of some indicators of primary tumor in influencing incidence, but not extension, of metachronous liver metastases and this is the main problem when it comes to using prognostic factors in order to modulate the intervals of postoperative follow-up according to risk category.

Vinorelbine as palliative therapy in advanced breast cancer

Thirty advanced breast cancer patients received Vinorelbine (VNB) according to two different schedules: a weekly i.v. bolus of 30 mg/m (14 patients) or a continuous infusion (CI) schedule comprising 8 mg i.v. bolus on day 1 followed by 8 mg/m2/die CI day 1 to 4, q 21 days (16 patients). 36% of patients had received at least two prior chemotherapy regimens for advanced disease and 57% had been treated with anthracycline-based palliative therapy. The overall response rate (CR + PR) was 33% (soft tissue 57%, bone 17%, viscera 29%). The main toxicities were neutropenia and abdominal pain. Vinorelbine is effective in pretreated advanced breast cancer patients.

A retrospective comparison of detection and treatment of breast cancer in young and elderly patients

The medical records of all women (297 cases) with breast cancer > or = 70 years of age, presenting at our Institute from January 1980 to December 1989, were reviewed. Data from 226 elderly women was compared to that from 100 stage-matched patients < 50 years of age, presenting during the same 10-year study interval. Conservative surgery was significantly more frequent in young patients (71.1%) compared to elderly women (26.1%) and radical mastectomy according to Halsted was undertaken in 34.3% of the elderly group compared to 8.9% of young patients (p < 0.001). Since 'incidental' diagnosis was significantly more frequent in the elderly group (59.9% versus 6.0%) (p < 0.001), primary care physicians may play an important role in the early diagnosis of breast cancer in the majority of elderly women.

[Evaluation of quality of life in oncology. Rationale and objectives of the first phase of the Quality of Life in Oncology project]

Although the subjective nature of quality of life perception is generally accepted, less attention has been paid to the procedure of selecting domains to be explored with questionnaires. In most cases domains are selected by panel of experts. It is not known whether these domains are relevant for the patients. Moreover, questionnaires developed in 'foreign' countries may not be culturally sound or relevant for patients living in different cultural background. In order to explore what really contributes to quality of life of Italian patients, a survey was conducted with the aim of identifying any dimension of quality of life, positively or negatively impacted on from the illness and therapies. A sample of two hundred and eighty eight cancer patients with previously specified characteristics (primary tumor, stage of disease and place of residence) were identified. After consenting to partecipate to the study, a staff member (a physician, a nurse or a psychologist) asked the patient to complete an open-ended questionnaire in the out-patient clinic or at home. This questionnaire, partially derived from a study by Padilla et al. made up of 5 questions: 'What does the term quality of life mean to you?', 'What contributes to a good quality of life?', 'What contributes to a poor or bad quality of life?', 'Which either physical or psychological symptom interferes with your quality of life?', 'State any positive or negative change in your quality of life, due to illness or treatments'. The first question was asked to explore the meaning of quality of life for the patient; the second and third question were asked to determine the contents of quality of life not health related; the fourth question and the diary provided information about quality of life contents related to his own experience of disease. Two hundred and forty eight questionnaires (86.1%) were obtained from 7 Cancer Centres participating to the study (Genova, Milano, Roma, Perugia, Napoli, Cagliari, Palermo). All the questionnaires were transcribed and subsequently broken down in phrases on a form that allowed coding. Three raters (a research nurse, an oncologist and a clinical psychologist) made the content analysis using as conceptual framework the list of domains identified by the Italian Society of Psycho-Oncology. The present study shows the possibility to define the content domain of quality of life attributes for cancer patients, using patients as experts.

Tamoxifen and interferon-beta for the treatment of metastatic breast cancer

It has been demonstrated, both in breast cancer cell lines and in metastatic breast cancer patients with cutaneous lesions that could be biopsied, that treatment with interferon beta (IFN-B) can increase expression of both estrogen (ER) and progesterone receptors (PgR). To evaluate the efficacy and toxicity of the combination of IFN and tamoxifen, 33 metastatic breast cancer patients were treated with the following regimen: IFN-B, 6.0 million units intramuscularly IU 3 times a week for two consecutive weeks followed by IFN-B 6.0 million IU im 3 times a week with concomitant tamoxifen 20 mg orally daily. Patients were pre and postmenopausal with median age of 60 years, median ECOG PS of 0, either ER positive or unknown, and had not received prior hormone therapy for metastatic disease. Overall objective response was observed in 9 (27%) patients. Complete response was observed in 2 cases and partial response in 7 patients. Median duration of response was 7 months (range 2-10). A higher response rate was observed in patients with predominantly soft tissue disease (38%) compared to patients with either dominant bone (18%) or visceral lesions (17%). Toxicity was mild and reversible: low grade fever in 30% of patients and flu-like symptoms in 9% of cases. It appears that IFN-B does not improve the efficacy of tamoxifen in an unselected population of metastatic breast cancer.

Radioimmunoguided surgery after primary treatment of locally advanced breast cancer

PURPOSE

To assess the role of radioimmunoguided surgery (RIGS) using a handheld intraoperative gamma-detecting probe (GDP) to identify neoplastic disease after primary chemotherapy in locally advanced breast cancer (LABC) patients injected with iodine 125-labeled monoclonal antibodies (MAbs).

PATIENTS AND METHODS

Twenty-one patients with histologically documented LABC were treated with a combined modality approach. After three courses of primary chemotherapy and before modified radical mastectomy, the 125I-radiolabeled MAbs B72.3 (anti-TAG72) and FO23C5 (anti-carcinoembryonic antigen [CEA]) were administered to 11 patients (group A) and 10 patients (group B), respectively. At surgery, a GDP was used to locate the primary tumor and to assess possible tumor multicentricity and the presence of ipsilateral axillary metastases. Routine pathologic examination was performed in neoplastic and normal tissue specimens of all 21 patients. In addition, immunohistochemical assay for TAG72 and CEA expression was performed.

RESULTS

In group A patients, RIGS identified primary tumor in seven of 11 patients (63.3%) and unpalpable multicentric tumor lesions were located in two of four (50%). Positive axillary lymph nodes were histologically documented in eight of 11 patients (72.7%) and RIGS identified three of eight (37.5%). In group B, RIGS located the primary tumor lesion in four of 10 patients (40%); in two cases, the tumor was not clinically evident. Multicentricity was observed in one of two patients and lymph node involvement in three of nine (33.3%). No false-positive results were observed in either group A or B.

CONCLUSION

RIGS appears to be a safe and reliable technique. However, the MAbs used in this study are not sufficiently specific. RIGS represents a technique for which the full potential for intraoperative assessment of breast cancer lesions can be reached when more specific antibodies become readily available.

Randomized cooperative study of perioperative chemotherapy in breast cancer

PURPOSE

The aim of this multicentric randomized trial was to determine whether reducing the interval between surgery and chemotherapy improves the outcome of breast cancer patients.

PATIENTS AND METHODS

Between June 1985 and July 1992, 600 breast cancer patients, clinical stages T1-3A,N0-2,M0 were randomly assigned to a perioperative cycle (PC) of cyclophosphamide 600 mg/m2, epidoxorubicin 60 mg/m2, and fluorouracil 600 mg/m2 (CEF). Node-negative (N-) patients did not receive any further treatment. Node positive (N+) patients received 11 cycles if previously given PC, or 12 cycles of CEF alternated with cyclophosphamide 600 mg/m2, methotrexate 40 mg/m2, and fluorouracil 600 mg/m2 (CMF). In addition, N+ patients received concomitant or sequential 5-year tamoxifen therapy.

RESULTS

At a median follow-up duration of 5.7 years, no significant difference in survival (88% v 84%, P = .3) between the two treatment arms was seen. However, a difference of borderline significance in relapse-free survival (RFS; 76% v 70%, P = .053) was evident. A significant survival advantage for the PC arm was detected only in the estrogen receptor-negative (ER-) patients (P = .003). RFS was significantly improved in N- patients, postmenopausal patients, and ER- patients. Multivariate analyses show that pathologic tumor size, nodal status, receptor status, and treatment (only in ER- patients) are significantly correlated with survival and RFS. PC toxicity did not influence wound healing.

CONCLUSION

This study provides preliminary evidence that PC positively affects relapse rate and survival in some subgroups, namely, ER- patients.

Mitoxantrone in elderly women with advanced breast cancer: a phase II study

Comorbidity has important implications in older breast cancer patients. Whether elderly patients are more likely to have a decreased tolerance to antineoplastic agents is still a question of debate. Chemotherapy-naive women with metastatic or locally advanced breast cancer aged > or = 68 years entered a phase II trial of Mitoxantrone given day 1 q 21 days. The dose of the drug was dependent on performance status (PS) and number of "minor" comorbid conditions: patients with ECOG PS = 2 and/or > or = 2 comorbid conditions received 10 mg/m2 and those with PS < 2 and < 2 comorbid conditions received 14 mg/m2. Twenty-seven patients, median age 77 years (range 68-86), received a median number of 5 courses (range 1-9). All 27 patients were evaluable for toxicity and 23 cases (patients receiving at least 3 courses) were evaluable for response. Partial response was observed in 6/23 cases (26%) and median duration of response was 6 months (range 3-9). Median overall survival was 8 months (range 2-34). Among cases receiving 10 mg/m2, 4 PR, 4 SD and 2 P were observed and in cases treated with 14 mg/m2, 2 PR, 5 SD and 6 P occurred. Treatment was well tolerated and no grade 4 toxicity was encountered. Mitoxantrone is an effective and well-tolerated regimen in elderly breast cancer patients presenting with comorbid conditions.

Locally advanced non-metastatic breast cancer: analysis of prognostic factors in 125 patients homogeneously treated with a combined modality approach

125 stage III breast cancer patients, including 51 cases of inflammatory carcinoma, were treated with the following combined modality approach: three courses of primary 5-fluorouracil, doxorubicin, cyclophosphamide (FAC) chemotherapy followed by locoregional treatment and subsequent adjuvant chemotherapy consisting of three courses of FAC alternating with three courses of cyclophosphamide, methotrexate, 5-fluorouracil (CMF). Clinical response to primary FAC was 65% (complete 10%). Residual tumour mass in the mastectomy specimen was > 1 and < or = 1 cm in 82 and 18% of cases, respectively. Complete pathological response following primary chemotherapy was achieved in only 3.5% of cases. After primary FAC and local treatment, 97% of patients were disease-free. Overall survival (S) and progression-free survival (PFS) at 5 years were 56 and 34%, respectively. Univariate analysis showed that age, receptor status and clinical and pathological response to primary chemotherapy did not appear to influence treatment outcome significantly, whereas stage, presence of inflammatory disease and number of involved nodes had a significant impact on both S and PFS.

Prevention of delayed emesis with metoclopramide and dexamethasone in patients receiving moderately emetogenic cytotoxic treatment

Forty-three untreated cancer patients receiving moderately emetogenic polychemotherapy entered a phase II trial in order to evaluate the effectiveness of the combination of metoclopramide (40 mg every 6 hrs) and dexamethasone (8 mg every 12 hrs) in the prevention of delayed emesis (days 2-3). For the control of acute emesis all patients received on day 1 ondansetron 8 mg for 3 times. Results of antiemetic treatment were as follows: complete/major protection from acute emesis (day 1) was observed in 72%/88% of patients. Worst day analysis of delayed emesis (days 2 and 3) showed that complete/major protection was obtained in 93%/95% of cases, respectively. Delayed nausea was not as well controlled: complete/major protection was observed in 44%/79% of patients. Extrapyramidal reactions occurred in 3 patients and moderate epigastric pain was reported by 3 patients. Since control of acute emesis could be one of the most important factors influencing delayed emesis, the absence of acute symptoms in 72% of our patients may be partially responsible for the excellent control of delayed emesis. The combination of metoclopramide and dexamethasone is a feasible and effective treatment for delayed emesis in outpatients receiving moderately emetogenic chemotherapy.

Long-term prognosis following macroscopic complete response at second-look laparotomy in advanced ovarian cancer patients treated with platinum-based chemotherapy. The Gruppo Oncologico Nord Ovest

Survival (S) and progression-free survival (PFS) were evaluated in 129 advanced ovarian cancer patients, who achieved a macroscopic complete response (112 pathological complete response and 17 microscopic disease) at second-look after platinum-based combination chemotherapy with or without doxorubicin (DX). The impact on S and PFS of age, performance status (PS), stage, histology, grade (G), residual disease after first surgery (RD), chemotherapy regimen, disease status at second-look and consolidation therapy were evaluated by univariate and multivariate analysis. In the 118 months observation period, median S and PFS were 81 and 34 months, respectively. Stage, G, RD, PS and disease status at second-look had significant impact on both S and PFS in univariate analysis, whereas consolidation therapy did not influence outcome. Cox's regression analysis showed that G, RD and PS had an independent impact on PFS. Test for interaction demonstrated no statistically significant relationship between RD, chemotherapy regimen and outcome. In conclusion, advanced ovarian cancer patients with macroscopically complete remission at second-look have a substantial risk of relapse after aggressive treatment. The risk of recurrence was estimated to be maximal in the first 3 years after restaging, and was correlated with poor PS, RD > 2 cm after first surgery and undifferentiated tumour.

Ondansetron and dexamethasone versus standard combination antiemetic therapy. A randomized trial for the prevention of acute and delayed emesis induced by cyclophosphamide-doxorubicin chemotherapy and maintenance of antiemetic effect at subsequent courses

The antiemetic efficacy of ondansetron and dexamethasone (Ondex) was randomly compared to that of high-dose metoclopramide, dexamethasone, and orphenadrine (Control) in the prevention of emesis induced by cyclophosphamide-doxorubicin chemotherapy in 64 chemotherapy-naive breast cancer patients. For the control of acute emesis (day 1), patients were randomized to receive either ondasetron 8 mg p.o. 1 hour prior to chemotherapy (CT) and repeated after 6 and 12 hours plus dexamethasone 20 mg i.v. 40 minutes prior to CT (Ondex) or dexamethasone 20 mg i.v. 40 minutes prior to CT, orphenadrine 40 mg i.m. 35 minutes prior to CT and metoclopramide 3 mg/kg i.v. 30 minutes prior to CT and repeated after 90 minutes followed by 40 mg p.o. every 3 hours for 4 times (Control). To control delayed emesis, patients on Ondex received ondansetron 8 mg PO t.i.d. days 2 and 3 and patients in the Control arm received metoclopramide 0.5 mg/kg p.o. q.i.d. and dexamethasone 8 mg i.m. b.i.d. days 2 and 3. Complete and major control of acute emesis was observed in 74%/94% and 44%/67% of patients treated with Ondex and Control, respectively (p < .01/p < .005). Acute nausea was absent in 38% and 34% of patients treated with Ondex and Control, respectively (p = NS). Complete and major control of delayed emesis (days 2-5) was observed in 65%/91% versus 44%/66% of patients in the Ondex and Control arms, respectively (p = NS/p < .01). In patients receiving 6 courses of FEC/FAC, control of acute emesis was significantly superior with Ondex at all treatment courses.

Breast-cancer in the elderly - detection and treatment modalities in 341 women

Elderly cancer patients are generally excluded from entry to clinical trials;and often managed inadequately or based on individual experience. We have retrospectively determined tumor detection modality, diagnostic and staging work-up, delay in referral and therapeutic approaches in 341 women with breast cancer aged over 70 years. Fifty-eight per cent of patients were in the 70-75 group of age. Our data suggest that tumor is detected during medical visit or hospitalization for reasons other than breast cancer in 63.1% elderly women with 74.1% of tumors diagnosed on stage I+II disease; the interval between patient's awareness of a breast nodule and first diagnostic and/or therapeutic intervention was less than 3 months in 51.4% and between 3 and 6 months in 20.7% of patients. Most of our patients received adequate treatment although in 18.6%, 26.8% and 18.2% of stage Il, III and IV respectively systemic treatment was not administered after surgery. A large proportion (22.3%) of patients received Halsted mastectomy and only 11.1% conservative surgery. We suggest breast examination should be encouraged, screening program should be extended after the age of 70 years and systemic treatment should be evaluated in elderly patients.

Preoperative Intra-Arterial Mitomycin-C in the Management of Sigmoid Adenocarcinoma: Long-Term Results of a Pilot Study

Aims and background

In patients undergoing potentially curative surgery for colorectal adenocarcinoma, the presence of occult disease is thought to be responsible for distant metastases, particularly of the liver. During the 1980's preoperative intra-arterial chemotherapy was used in patients with adenocarcinoma of the sigmoid colon since it was thought that the biological effects induced by radiation in rectal lesions could be induced by cytotoxic agents in sigmoid cancer which was found to be less sensitive to radiation. The aim of the present paper is to report long-term results of an early pilot study on 20 patients with sigmoid colon adenocarcinoma treated with a 6 preoperative intra-arterial infusion of mitomycin-C followed by curative surgery.

Methods

From January 1980 to December 1986, 20 patients with adenocarcinoma of the sigmoid colon were treated with a 6 hours preoperative intra-arterial infusion of mitomycin-C followed by potentially curative surgery (Group A). Eighteen hours prior to surgery the patients underwent selective arteriography of the inferior mesenteric artery through puncture of the femoral artery at the inguinal fold. The Seldinger technique was applied and Cook BP6 catheter was used. At the end of the examination, the catheter was positioned in the inferior mesenteric artery and mitomycin-C, 10 mg/m2, was infused in 500 mi of normal saline over a 6 hours period after which the catheter was definitively removed. Within 18 hours following intra-arterial mitomycin-C infusion all 20 patients underwent potentially curative surgery of their sigmoid adenocarcinoma. During the same period, 48 comparable sigmoid colon cancer patients underwent potentially curative resection alone (Group B).

Results

At 5 years overall recurrence rate was 30% and 39.6% in Group A and B patients, respectively (P = n.s.). In patients with Stage C disease, recurrence was less frequently observed in Group A (44.4%) than in Group B (77.7%) (P = n.s.). Overall survival at 5 years was comparable in the two groups of patients (70% and 64% for Group A and B, respectively) and median survival was >60 months in both groups. In patients with Stage C lesions, there was a trend for improved survival at 5 years in Group A patients (55%; median >60 months) compared to Group B (22%; median 27 months) patients (P = n.s.).

Conclusions

Although the difference indicating decreased recurrences and improved survival for Stage C patients treated with preoperative intra-arterial mitomycin-C were not statistically significant, the long term results of this small pilot study are encouraging.

Primary mucinous adenocarcinomas and signet-ring cell carcinomas of colon and rectum

Of 352 patients with colorectal carcinoma followed for a minimum of 5 years after surgery, 39 cases (11.1%; median age 60 years) had mucinous adenocarcinoma, and 4 (1.1%; median age 62 years) had signet-ring cell carcinoma. Mucinous carcinomas were most frequently located in the rectum (61.5%) and in the sigmoid colon (15.3%) and presented with stage C and D disease in 41 and 15% of the cases, respectively. Disease recurrence was more frequently observed in patients with mucinous (51.7%) or signet-ring lesions (100%) as compared with adenocarcinomas. Five-year survival was 45 (median 48 months), 28 (median 27), and 0% (median 15 months) in patients with adenocarcinomas, mucinous adenocarcinomas, and signet-ring cell carcinomas, respectively (p < 0.05). Mucinous carcinomas of the rectum had had a significantly worse prognosis (5-year survival 17%, median 33 months) as compared with adenocarcinomas of the same site (5-year survival 34%, median 25 months; p < 0.05).

[Tropisetron versus ondansetron in the prevention and control of emesis in patients undergoing chemotherapy with FAC/FEC for metastatic or surgically treated breast carcinoma]

OBJECTIVE. To compare the efficacy and tolerability of standard dosage of tropisetron and ondansetron in controlling emesis induced by chemotherapeutic regimen not containing cisplatin. DESIGN. Open, comparative, parallel-group, randomized study. SETTING. Day hospital to which patients were admitted only on the day on chemotherapy when the antiemetic was given intravenously.

PATIENTS

Forty adult women with metastatic or operated breast cancer who could benefit by adjuvant treatment.

EXCLUSION CRITERIA

pregnancy, breast-feeding, symptoms of intracranial hypertension, current medical conditions which could put the patient at risk (e.g. severe cardiac insufficiency, uncontrolled infection, etc.), abnormal bowel rhythm, and treatment with antitumoral drugs in the previous 6 months. TREATMENT. During three cycles of chemotherapy with FAC/FEC (600 mg/m2 5-fluro-uracil, 600 mg/m2 cyclophosphamide and 50 mg/m2 adriamycin or 60 mg/m2 epidoxorubicin) antiemetic treatment was given as follows: tropisetron 5 mg/day (in intravenous infusion before chemotherapy and then orally for 4 days) or ondansetron 8 mg x 3/day (the first dose intravenously before chemotherapy and the subsequent doses orally until the end of the fourth day after chemotherapy).

OUTCOME MEASURES

Severity of nausea and number of vomiting episodes each day during antiemetic treatment; ECG; vital signs and blood tests before each cycle and at the end of the study; side effects.

RESULTS

On the worst day of the three cycles complete control of emesis was obtained in 50, 75 and 84.6% of the patients treated with tropisetron and in 60, 58.8 and 66.7% of those who received ondansetron, the differences being not significant (p > 0.05). The only side effects were headache (in 1 patient given tropisetron) and skin rash (1 given ondansetron).

CONCLUSIONS

The efficacy and tolerability of 5 mg/day of tropisetron and 24 mg/day of ondansetron were almost identical.

Relationship of variations in tumor cell kinetics induced by primary chemotherapy to tumor regression and prognosis in locally advanced breast cancer

The relationship of changes in 3H-thymidine labelling index (TLI) induced by primary chemotherapy to tumor response and relapse rate in 36 patients with previously untreated locally advanced breast cancer (LABC) was analyzed. All patients received primary chemotherapy (3 cycles FAC), followed by mastectomy and subsequent adjuvant chemotherapy (3 FAC alternated with 3 CMF). Tumor TLI was evaluated immediately prior to primary chemotherapy and at the time of mastectomy. Median pretreatment TLI was used to discriminate between tumors with a high or low proliferative rate. Clinical objective response to primary chemotherapy was 83% in patients with high TLI and 56% for those with low pretreatment TLI (p = 0.06). Primary chemotherapy induced a > or = 50% reduction of the proliferative rate in 83% and 39% of the tumors with high and low pretreatment TLI, respectively (p = 0.006). Patients were classified into 4 groups according to TLI values both before and after primary chemotherapy: patients who remained in the high TLI group after primary FAC had the highest response rate (100%) and the lowest 2-year relapse rate (20%). These data suggest that: a) improved response to aggressive cytotoxic treatment occurs in tumors with high TLI at diagnosis; b) there is a significant correlation between TLI changes induced by primary chemotherapy and pretreatment proliferative activity; c) patients who remain in the high TLI group after primary chemotherapy are more likely to benefit from subsequent adjuvant systemic therapy.

Phase II study of weekly mitoxantrone, 5-fluorouracil, and leucovorin in metastatic breast cancer

A phase II study to test the toxicity and the efficacy of a weekly combination of Mitoxantrone, 5-Fluorouracil and L-Leucovorin (MFL) was carried out in 43 patients with metastatic breast cancer. Chemotherapy consisted of mitoxantrone 4 mg/m2, 5-fluorouracil 375 mg/m2, and L-leucovorin 100 mg/m2 on day 1, weekly. Patient characteristics were: median age 53 years (range 36-65); estrogen receptor (ER) status was known in 26 patients and of these 15 (57.7%) patients were ER-positive and 11 (42.3%) ER-negative. Of the 43 patients, 25 (58.1%) and 18 (41.9%) patients had received prior adjuvant chemotherapy and prior adjuvant endocrine treatment, respectively. MFL was administered to 22 (51.1%) patients as first line chemotherapy for advanced disease, while 21 (48.9%) patients had received 1 to 2 cytotoxic regimens for metastatic disease. The dominant sites of metastases were: soft tissue in 11 (25.5%) patients, bone in 8 (18.6%) patients and viscera in 24 (55.9%). All patients were assessable for toxicity: only 8 patients experienced WHO grade 3 leukopenia. Thrombocytopenia, diarrhea, stomatitis, and nausea/vomiting were negligible. Anemia and alopecia were not observed. Thirty-nine patients were assessable for response: overall response rate was 28.2% (complete response 7.7% and partial response 20.5%). Median duration of response was 12 months (range 6-34). Patients with no prior anthracyclines had a 42.1% response rate compared to 15% in patients who had received anthracyclines. Median overall survival of the 43 patients was 6 months (range 1-34). Weekly MFL is a well-tolerated and a moderately effective regimen for the treatment of metastatic breast cancer.

Primary gastric lymphoma

The records of 30 patients with primary gastric lymphoma and a minimum of 5 years of follow-up were reviewed and clinical and pathologic prognostic factors analyzed. The overall 5-year survival was 40% (median 23 months). No significant relationship between surgical and patient age, sex, duration of symptoms, macroscopic appearance, or size of the primary lesion or degree of serosal infiltration was demonstrated. Stage of disease and site of primary had an impact on prognosis. Survival was improved in patients with stage I-II disease (P < 0.05) and in patients with primary located in the distal third of the stomach (P < 0.05). Although histology in all three classifications did not correlate well with survival, patients with low-grade lymphoma according to Kiel showed improved outcome (P < 0.05). Five-year survival of 11 patients with positive lymph nodes, 6 of whom were treated with cytotoxic therapy, was 54% and comparable to that of 7 patients (56%) with no nodal involvement who did not receive chemotherapy after surgery.

Cerebral metastases secondary to ovarian cancer: still an unusual event

An incidence of cerebral metastases secondary to epithelial ovarian cancer as high as 11.6% has been reported in small series and related to the prolonged survival of ovarian cancer patients treated with platinum compounds (Hardy, J. R., and Harvey, V. J. Gynecol. Oncol. 33, 296-300, 1989). A review of the histories of 413 ovarian cancer patients, treated from 1981 to 1989 with platinum-based combination chemotherapy according to the protocols of the Gruppo Oncologico Nord Ovest (GONO) (North West Oncology Group), showed that only 9 patients (2.2%) developed clinical evidence of cerebral metastases. Six of 9 patients had FIGO Stage IIIc disease and 1 each with FIGO Stages Ic, IIc, and IV. All these patients had received cisplatin or carboplatin-based combination chemotherapy. Clinical response to initial cytotoxic therapy was as follows: complete response, 3 patients; partial response, 4 patients; stable disease, 1 patient; progressive disease, 1 patient. Cerebral metastases occurred at a median of 19 months (range 3-36) from diagnosis and median survival of patients with central nervous system (CNS) metastasis was 26 months (range 10-81) from diagnosis of primary disease and 8 months (range 1-45) from diagnosis of CNS involvement. The incidence of CNS metastases in our series is similar to that reported in the past and significantly lower than figures reported by the above mentioned paper. On the basis of our data we do not agree with Hardy and Harvey about the relationship possibly existing between prolonged survival and incidence of CNS metastases and, particularly, about the need for prophylactic cranial irradiation.

The impact of received dose intensity on the outcome of advanced ovarian cancer

It has been demonstrated that the prognosis of ovarian cancer is influenced by the dose intensity of cytotoxic treatment. The impact of received dose intensity of platinum-based combination chemotherapy on disease outcome was analysed in 226 stage III-IV ovarian cancer patients entered into two prospective randomised trials. All patients received either cisplatin or carboplatin and cyclophosphamide with or without doxorubicin for six courses after primary surgery. The impact of the received dose intensity of each drug (RDI), the average received dose intensity of the treatment regimen (ARDI) and the relative total drug dose (RTD) on progression-free survival (PFS) and survival were analysed. In the 198 patients receiving the full six courses of treatment, RDI of cisplatin or carboplatin, ARDI and RTD were > 0.76 in 74.2, 61.1 and 65.1% of cases, respectively. Although the differences were not significant, pathological complete response was more frequently observed in the group of patients with ARDI < 0.75, whereas the partial response rate was higher in the ARDI > or = 0.76 group. Median survival and PFS were 19 and 13 months; 22 and 10 months; 23 and 13 months for the groups of patients receiving chemotherapy at a ARDI of < 0.75, > or = 0.76-0.99 and > 1.00, respectively (P = not significant). It appears that modest dose modifications and brief treatment delays during first-line platinum-based chemotherapy do not affect response rate, survival and PFS in advanced ovarian cancer patients.

Correction of type II breast deformities following conservative cancer surgery

Breast deformities following conservative cancer surgery are seen with increasing frequency and often represent difficult reconstructive problems. Type II deformities are characterized by localized tissue insufficiency, which can be due to skin insufficiency (type IIa), subcutaneous tissue insufficiency (type IIb), or both (type IIab). Correction of a locally damaged breast is a surgical challenge that can result in a fully restored breast if selection of the surgical procedure is properly carried out. A series of 37 patients who underwent correction of type II deformities from 1980 to 1989 was reviewed. Results obtained with different surgical procedures, including simple submuscular placement of traditional or expandable implants, breast reshaping, transposition of a latissimus dorsi muscle or musculocutaneous flap, TRAM flap, and reverse abdominoplasty, were evaluated. Aesthetic outcome was judged to be good or excellent in 78 percent of patients. Guidelines for selection of the most appropriate surgical procedure according to the defect's etiology, morphology, and location and to the breast's size and shape are presented.

Extension of lymph node dissection and survival in primary gastric cancer

The histories of 429 patients who underwent surgery for primary gastric cancer at our ward from January 1970 to December 1985, were reviewed. All patients underwent surgery: potentially curative surgery, 54.8%, non-curative resection, 18.2%; palliative surgery, 27%. Nodal status was as follows: N0, 28%; N1, 17.7%; N2, 44.5%; N3, 9.8%. The incidence of N0 cases was significantly increased in Stage T1 and T2 disease compared to Stage T3 and T4 lesions (p < 0.001). In Stage T3 and T4 patients the incidence of distant metastases increased if lymph node involvement was also present (p < 0.005). In patients without nodal metastases 5-year survival was 70% (median survival: 60+ months) whereas, in patients with lymph node involvement survival was 32% (median survival: 24 months) (p < 0.001). Our data suggest that elective extensive lymph node dissection (R2) is indicated in all patients because survival is improved by this procedure. We recommend R3 lymph node dissection only in macroscopic N3 node involvement patients.

Efficacy of twice daily versus three times daily oral ondansetron in the prevention of chemotherapy induced emesis: a randomized, single-blind, multicentre study. The Ondansetron International Emesis Study Group

Following a single intravenous dose given pre-chemotherapy, the efficacy and tolerability of oral ondansetron treatment given twice daily was compared with the established three times daily oral supplementary regimen in the prophylaxis of nausea and vomiting induced by cyclophosphamide (greater than or equal to 500 mg/m2) in combination with doxorubicin (greater than or equal to 40 mg/m2) or epirubicin (greater than or equal to 40 mg/m2). Oral ondansetron given twice daily or three times daily was equally effective in controlling nausea and emesis. The twice daily oral treatment prevented emesis in 73% of patients in the first 24 hours and in 65% of patients over 3 days. Both dose schedules were safe and were tolerated well. Twice daily oral ondansetron showed good efficacy for controlling emesis and nausea in oncology outpatients.

Prognostic factors in node positive primary breast cancer patients treated with adjuvant CMF

The influence of various patient and disease-related parameters on survival (S) and disease-free survival (DFS) in 217 node positive primary breast cancer patients treated with surgery followed by adjuvant i.v. cyclophosphamide, methotrexate, and 5-fluorouracil (CMF) was evaluated by univariate and multivariate analyses. Five year actuarial S and DFS were 73.3% and 54.8%, respectively. Univariate analysis revealed that patient age, number of involved axillary nodes and ER status had a significant impact on both S and DFS. PgR positive tumors had improved DFS but no S difference was observed. Menopausal status predicted S but not DFS. Primary tumor size and CMF-induced amenorrhea did not predict disease outcome. Multivariate analysis demonstrated that only degree of nodal involvement and PgR status had independent significant impact on prognosis. Both S and DFS are significantly influenced by the number of involved nodes, whereas improved DFS but not S was evident in patients with PgR positive tumors.

In vitro antimicrobial effects of fresh split skin, homologous-cultured epithelium and porcine split skin grafts for wound coverage

Various biological dressings, for example, human fresh and cadaver skin grafts, homologous cultured human epithelium and deep frozen porcine split skin (Lyocutis), have been used to treat skin loss. Each of these biological dressings has its advantages and disadvantages. The antimicrobial properties of each dressing type are important since bactericidal activity influences the lifespan of the transplanted tissue. In the present study the in vitro antimicrobial effects of human fresh skin, homologous cultured epithelium and Lyocutis were compared to in vivo bactericidal activity of these dressings and possible clinical applications are recommended.

The impact of chemotherapy on the quality of life of breast cancer patients

One hundred and thirty-seven breast cancer patients, 102 receiving adjuvant chemotherapy and 35 receiving palliative chemotherapy for metastatic disease underwent a 37-item quality-of-life questionnaire to evaluate the impact of disease and treatment on physical, psychological and social well being. Patient groups were designated as follows--Adj CT: patients undergoing the questionnaire during their adjuvant chemotherapy program; Post Adj CT: patients evaluated 3 to 8 months after termination of adjuvant chemotherapy; Mts CT: patients assessed during palliative chemotherapy for metastatic disease, and Post Mts CT: patients 3 to 8 months after termination of palliative chemotherapy. Physical and social activities were reported as unaltered or normal by 64 to 70% and 52 to 67% of patients, respectively. Psychological status was judged normal by 39 to 45% of patients. No significant differences were observed between the patients groups. In 83 to 90% of cases the patient normally took care of herself. In 62 to 87% of cases time dedicated to recreational activities was reported as unaltered. The majority of patients (84%) judged that their relationship with partner and/or family were good. Severe anxiety was reported in 19 to 28% of patients and severe depression was infrequent (3.9%). Information regarding disease and treatment given by health professionals was considered satisfactory by 80 to 100% of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Mitoxantrone and mitomycin C as second-line treatment for advanced breast cancer

Forty-three evaluable patients with advanced breast cancer were treated with a combination of mitoxantrone 10 mg/sqm and mitomycin C 10 mg/sqm every 3 weeks. Two patients (4%) achieved objective responses lasting 3 and 16 months. The median duration of survival after protocol entry was 6 months (range 1-22) and the median progression-free survival was 3.5 (range 1-20). Only mild toxicities were observed. We concluded that the mitoxantrone and mitomycin C combination has limited toxicity but low activity and only brief disease palliation in advanced breast cancer.

Tamoxifen and alpha interferon in advanced breast cancer

Thirteen pretreated advanced breast cancer patients received a combination of alpha interferon 5 million IU every 2 days, subcutaneously, plus tamoxifen 10 mg 3 times daily, until disease progression. The objective response rate was 15.4%: 1 patient achieved a complete response, 1 a partial response and 11 demonstrated stable disease; half of the patients were receptor negative and/or pretreated with hormonotherapy. Durations of response were 16 and 26 months for the CR and PR patients respectively; median progression-free survival was 4 months (range 0-26). Toxicities were registered according to WHO criteria: 4 patients stopped the treatment with interferon because of severe flu-like symptoms, while in the others the combination was generally accepted with good tolerance.

Oral ondansetron (GR 38032F) for the control of CMF-induced emesis in the outpatient

The efficacy of the serotonin antagonist ondansetron (GR 38032F) was evaluated in the prevention of nausea and vomiting induced by CMF chemotherapy in 29 breast cancer patients. At their first treatment course of CMF, all given IV on day 1 q 21 days, patients were given oral antiemetic treatment as follows: ondansetron 8 mg, 2 h prior to CMF, repeated after 5 and 10 h the day of chemotherapy and then 8 mg tds for a minimum of 3 days to a maximum of 5 days following chemotherapy. At first course of CMF, complete protection from emesis and nausea was observed in 86.2% and 62% of patients, respectively. At subsequent CMF courses with ondansetron, complete control of emesis was observed in 80% of patients. Side effects were mild and no dystonic reactions were observed. Ondansetron represents an effective, safe, and easily administered outpatient regimen. The addition of a corticosteroid to ondansetron could further improve control of CMF-induced emesis.

Ifosfamide and etoposide salvage treatment in advanced ovarian cancer

Twelve FIGO stage III-IV ovarian cancer patients progressing or relapsing after primary cisplatin-containing combination chemotherapy were treated with ifosfamide and etoposide. Only patients with clinically evaluable disease entered the trial. The 12 patients received a median number of 3 courses (range 1-6). No complete or partial response and two disease stabilizations were observed. Ten patients progressed on therapy. The combination of ifosfamide and etoposide does not appear to be an effective salvage treatment for advanced ovarian cancer.

The incidence of narcotic-induced emesis

Epidemiologic studies of the incidence of emesis induced by narcotic analgesics are lacking. The histories of 260 cancer patients receiving oral narcotic analgesics prescribed at the Pain Clinic of our Institute from December 1988 to December 1989 were reviewed. Of the 260 patients, 120 were women, median age 61 (range 30-90) yr and 140 were men, median age 62 (range 30-82) yr. Nausea and vomiting associated with assumption of the various narcotics were buprenorphine 8.3% and 22.7%, morphine 18.3% and 28%, codeine 16.2% and 29.7%, and oxycodone 10% and 40%, respectively. Since the use of narcotic analgesics can effectively relieve pain and improve quality of life in cancer patients, it is important to be aware of the incidence of narcotic-induced emesis in order to use appropriate prophylactic antiemetic therapy.