Needs in breast cancer patients (pts) during chemotherapy: Customer satisfaction evaluation

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Background: Satisfied patients demonstrate higher levels of compliance for the course of their treatment and the probability of successful treatment completion thus considerably increases. Analysis of pts needs is the base of pts satisfaction. The present analysis aims to identify the needs of our in-outpatients who received chemotherapy. Methods: 134 pts with breast cancer who underwent chemotherapy during 3 months (from 15 September to 30 November) were eligible for study. We administered the “Need Evaluation Questionnaire” (NED) validated by U.O. Psiconcologia Istituto Nazionale Tumori Mi) to 125 pts after consent, 9 pts (7%) refused to answer items. NED was built on 23 items in 7 domains of necessity: 1) information on diagnoses, prognoses, diagnostics tests and treatments (items 1–4); 2) relationship between pts and physicians or nurses (items 5–8), 3) nursing and supportive care (items 9 -13) 4) Hospital service (item 14); 5) economical aspects (items 15–16); 6) psychological, ethical, spiritual care (items 17,18,19,23); 7) relationship with relative. NED makes a quantitative evaluation of necessity with simple questions. Eligibility criteria required age ≥ 18 yrs (median age of pts was 55 yrs), histologically proven breast cancer; at lest 1 completed cycles of neoadjuvant or adjuvant or palliative chemotherapy. 96 (77%) pts completed questionnaire by their self, and 29 pts (23%) were helped because of practical problems (infusional therapy, no glasses at so on ). We choose a descriptive quantitative statistical evaluation for every item. Results: 93 % of pts completed NED questionnaire. More significant data were reported afterward and answers were allocated among the 7 domains: 1) more information about prognosis was required by 52 % of pts; 2) 90 % of pts thought that physicians embroiled them in therapeutic choices, but 36% of pts required information about future and quality of life 3) 96% of pts considered very good nursing care; 4) positive for all pts 5) 26% of pts required more informations about insurance, tickets 6) 13 and 14 % of pts required psychological or spiritual relationship; 7) women generally had support by relatives. Conclusions: this analysis shows that needs of our pts generally received responses, but answers also emphasized assurances on pts’ future.

No significant financial relationships to disclose.

Proliferation heterogeneity in synovial sarcoma (SS) defines different patterns of clinical outcome: A retrospective study of 32 patients

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Background: SS is an aggressive soft tissue sarcoma (STS) characterized by a constitutive overexpression of the bcl-2 proteins and high proliferation rate (Ki67). The aim of the study was to evaluate prognostic value of proliferative activity and apoptosis in SS. Methods: A retrospective analysis of 32 patients treated at three oncology centers between January 2000 and August 2008 was conducted. Histologic diagnosis of SS was confirmed by FISH analysis of t(X;18). Bcl-2 and Ki67 were determined by immunohistochemistry at baseline and after neoadjuvant chemotherapy (CT). A cut-off value of 20% was established for Ki67. The bcl-2 gene status was evaluated by FISH in neoadjuvant subgroup. Treatment-induced pathological response (pCR) was defined as tumor necrosis of 100%. Endpoints were recurrence rate (RR), disease-free survival (DFS) and overall survival (OS). Clinical and pathological variables were considered in uni- and multivariate analysis. Results: 13/32 patients received an anthracycline/ifosfamide-based chemotherapy (CT) before surgery. 8 pts received concomitant radiotherapy. A median number of 3 cycles of neoadjuvant CT was administered. All patients underwent surgical resection and pathologic assessment of the coexpression of bcl-2 and Ki67 was evaluated in the resected specimens. At baseline, all samples showed immunoexpression of bcl-2 and 9/13 had Ki67 more than 20%. After neoadjuvant CT, Ki67 was downregulated <20% in 11/13 samples and bcl-2 was negative in 4/13 pts. At FISH analysis, bcl-2 gene was neither rearranged nor amplified. After a median follow-up of 21 months (range 13–64 months), 9/13 pts without pCR experienced progression disease and 5 of them were dead of SS. At uni- and multivariate analysis, both pCR and downregulation of bcl-2 and Ki67 activity had a significant impact on DFS and OS (p=0.03). Conclusions: 1. Downregulation of bcl-2 and Ki67 index after treatment could be a predictor of recurrence and overall survival. 2. SS is characterized by cellular heterogeneity in which a high proliferative compartment coexists with low proliferative/anti-apoptotic compartment with different response to treatment.

No significant financial relationships to disclose.

Deep electro-hyperthermia (EHY) with or without thermo-active agents in patients with advanced hepatic cell carcinoma: Phase II study

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Background: Advanced HCC has no standard chemotherapy , all pts would be valuabled in clinical trials. We evaluated effectiveness and toxicity of capacitatively coupled low-frequency 13.56 MHz deep hyperthermia (Oncotherm-EHY 2000) treatment on chemo- refractory malignant primary liver cancer which underwent all other possible treatment. Methods: From February 2005 to July 2006, we enrolled 22 pts with advanced HCC. ECOG PS was 1 or O. Viral hepatic infection status was 7 HBV+, 8 HCV+, 1 HCV/HBV+. Median age was 67,5 y (range 63 -78), male/female 20/2 . 15 pts were uneligible for liver surgery, 3 pts received TACE, 1 PEI, 1 a lot of therapy. 7 pts were pre-treated with surgery, 2 also received TACE, 1 PEI and 1 a lot of therapy. 75% of pts were in stage C of BCLC classification. 2 pts had also distant metastases, 70% of pts had portal vein thromboses. 8 pts underwent only to EHY without CT. Schedule : EHY was achieved by arrangements of capacitative electrodes with a radiofrequency field of 13.56 Mhz (RF-DHT) at 80- 130 W equivalent to 41 °- 47° C for 60 minutes, 2 times/w for 5 weeks in combination with thermo-active agents . EHY was applied over 2 time a week over 1 hour as mono - combined therapy . Concomitant chemotherapy was oxaliplatin 50 mgr at fixed dose on D 1and D 15 . One cycle is 10 treatments of EHY ; 4 pts underwent 2 cycles and 2 pts to 3 cycles and 1 pt to 4 cycles . Median number of cycles was 1,5 (range 1–4), total EHY applications were 365. Results: EHY plus thermo-active drug is beneficial on clinical conditions off treated pts with an excellent compliance on out- patients. We observed 1 CR ( pt has only one bone metastases after 6 months without liver relapse), no PR, 25% of SD. Median survival time was 20’5 weeks (5 - 81+) We noted that 11 pts (50%) presented evidence of increasing well-being. Toxicity : 4 pts had skin reaction after application of EHY. In 3 pts we observed cutaneous hyperemia on the area of treatment and mild burn on the skin ; all symptoms disappeared after local steroid therapy , treatment was interrupted until resolution . Conclusions: Low toxicity and clinical benefit will be confirmed in further clinical studies. Capacitively coupled low-frequency 13.56 deep-hyperthermia is feasible for chemo-refractory HCC.

No significant financial relationships to disclose.

CXCR4/SDF-1 expression in early breast cancer (BC) is not influenced by circulating estrogens serum levels

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Background: The chemokine SDF-1 and its receptor CXCR4 have been found to enhance the metastatic potential of BC cells and correlate with a poorer prognosis of BC patients. Estradiol is a known mitogenic factor for BC cells. SDF-1 has been reported to be an estradiol (E2)-inducible autocrine growth factor that supports the growth of breast cancer cell lines in vitro. The aim of this study was to verify whether estrogens serum levels may influence SDF-1 and CXCR4 expression in vivo, in a series of patients with early stage BC. Methods: 68 patients sequentially observed at the Spedali Civili di Brescia from 2001 to 2002, with a diagnosis of T1a,b,c, N0 breast cancer were retrospectively analysed. CXCR4 and SDF-1 expression was determined by immunohistochemistry with anti-human CXCR4 (Clone 44716) and anti-human SDF-1 (Clone 79018) monoclonal antibodies (R&D Systems, Minneapolis, USA) followed by incubation with the EnVision peroxidase kit (Dakocytomation, Glostrup, Denmark). A serum sample was obtained from all patients at baseline before surgery. Serum estrone (E1) and estradiol (E2) were measured by radioimmunoassay by using commercial kits (Alifax, Padua, IT and Ortho-Clinical Diagnostics, Amersham, UK, respectively). Results: Estrogens serum levels analysis revealed elevated levels of E1 in 9/54 (16%) post-menopausal patients, while E2 levels were in the normal ranges. SDF-1 was expressed in 68/68 (100%) patients with a diffuse and intense cytoplasmatic pattern of staining and CXCR4 was coexpressed in 15/68 (22%) patients with a predominant faint nuclear distibution (p 0,06). No significant correlations were found between CXCR4, SDF-1 and E1 or E2, respectively, as well as with other clinico-pathological characteristics. After a median follow-up of 48 months, 3/68 (4%) patients which all resulted CXC4/SDF1-positive, relapsed and are dead for metastatic disease. Conclusions: This study demonstrates that in T1N0 BC patients: 1) SDF-1 is high levels in the majority of cases; 2) CXCR4 is expressed in approximately 20% of cases with restriction to the nucleus and 3) serum levels of circulating E2 and E1 in pre- or post-menopausal patients, respectively, do not influence CXCR4/SDF-1 expression on breast cancer cells.

No significant financial relationships to disclose.

IVM – the first choice for IVF in Italy

In March 2004, a new law was introduced in Italy to regulate assisted reproduction; at present it is impossible to use more than a maximum of three oocytes per IVF cycle, nor can embryos or prezygotes (2PN cells) be selected or cryopreserved. The prohibitions introduced by the new law have, on the one hand, reduced the expectations of success of current techniques and, on the other hand, stimulated clinicians and embryologists to work on new therapeutic strategies so as to offer the highest chances of success with the lowest risks. In-vitro maturation (IVM) of oocytes fits very well with these new requirements: ovarian stimulation is avoided and the handling of spare oocytes is facilitated. The IVM protocol is an intriguing alternative to conventional IVF techniques, since it removes the side-effects of drug stimulation, especially ovarian hyperstimulation syndrome, and it also reduces the costs of the entire procedure, both in terms of 'time consumption' and 'patient/society costs for drugs'. In the authors' IVF centre the IVM technique has been used for more than a year, with significant success in terms of maturation and fertilization rates, percentage of embryo transfers, number of pregnancies and, finally, healthy babies born.

Solitary breast metastases from a renal cell carcinoma

A case of solitary and metachronous breast metastases from a renal cell carcinoma is described nine years after surgery. The review of the literature proves that the breast is an unusual site for metastatic disease.

Role of puncture and aspiration in expectant management of simple ovarian cysts: a randomised study

OBJECTIVES

To assess the potential of expectant management for simple ovarian cysts diagnosed by transabdominal or transvaginal ultrasonography. To compare the results of needle aspiration with those achieved with simple observation.

DESIGN

Randomised trial.

SETTING

Hospital department of obstetrics and gynaecology.

SUBJECTS

278 women with simple cysts randomly allocated to simple observation (143) or ultrasound guided fine needle aspiration (135) between 1990 and 1994.

MAIN OUTCOME MEASURES

Resolution of cyst or development of malignancy.

RESULTS

After six months 269 were available for follow up. The rate of resolution was 46% (59/128) with aspiration and 44.6% (63/141) with observation. Only the diameter of the cyst (P < 0.0001) was a significant independent prognostic factor for resolution in a multivariate analysis. Age and treatment had no significant effect. One woman was subsequently found to have borderline malignant changes on histopathological examination. Her cyst was detected by transabdominal ultrasonography.

CONCLUSIONS

Expectant management for up to six months does not cause risks for the patients and allows spontaneous resolution in over a third of cases, avoiding the costs and risks of unnecessary surgery. Aspiration does not provide better results than simple observation.

A randomized trial of open versus closed vaginal vault in the prevention of postoperative morbidity after abdominal hysterectomy

OBJECTIVE

Our purpose was to evaluate the effects of two surgical techniques, closed vaginal vault with two layers of continous 3-0 polyglactin suture versus open vaginal vault with a locking 3-0 polyglactin suture, after abdominal hysterectomy.

STUDY DESIGN

A prospective, randomized trial was performed. During the hospital stay and 4 to 8 weeks after the operation patients were observed for evidence of morbidity.

RESULTS

Of the 273 evaluable subjects, 141 had the vaginal vault left open whereas 132 were closed. Ten (7.1%) and eight patients (6.1%) had infections at the operative site (pelvis or abdominal wound) (p = 0.92). A urinary tract infection was diagnosed in three (2.1%) and in four subjects (3.0%) (p = 0.46). A pelvic hematoma developed in two patients of each group (p = 0.66). Vault granulations were recorded in 11% and 12% of subjects (p = 0.97).

CONCLUSIONS

This study failed to show some benefit in favor of either of the two surgical policies. A careful surgical technique and antibiotic prophylaxis seem to remain the most important factors in the prevention of postoperative morbidity.

Ultrasound-guided aspiration of endometriomas: possible applications and limitations

OBJECTIVES

To evaluate the role of needle aspiration in the management of endometriomas.

DESIGN

Retrospective evaluation of the activity of the section of interventional ultrasound in a single tertiary care institution.

SETTING

Department of Obstetrics and Gynecology, Ospedale S. Gerardo, Monza, University of Milan, Italy.

PATIENTS

Two hundred nine premenopausal patients underwent aspiration for diagnostic purpose (n = 166), for relief of symptoms (n = 25), or with therapeutic intent (n = 18).

RESULTS

Adequate material was obtained by all punctures. Early complications (self-limiting vagal symptoms or pain) occurred in eight cases. Short-term complications consisted of acute abdominal pain in three cases and infection in one. Three women required surgical treatment of the complication. At first examination after aspiration, persistence of the cyst was observed in all but four cases, including all cases who had undergone therapeutic aspiration. Nine patients reported relief of symptoms but six other patients referred onset or worsening of pelvic discomfort after aspiration.

CONCLUSIONS

Ultrasound-guided aspiration of endometriomas is feasible. The transvaginal route reduces early complication but implies a risk of infection of 1.3%. However, drainage alone is ineffective as a therapeutic procedure and the applications of aspiration of endometriomas appear limited to some cases with diagnostic intent.

HCV-RNA detection in ultrasound-guided fine needle biopsies of liver nodules and surrounding tissue

HCV-RNA was examined in serum and liver tissue obtained from 8 hepatitis B surface antigen (HBsAg) negative patients with liver nodules ranging in size from 2 to 11 cm. Histological examination of ultrasound-guided fine needle biopsies revealed the presence of hepatocellular carcinoma (HCC) in six patients (5 of whom were anti-HCV positive), cholangiocarcinoma in 1 patient (anti-HCV positive) and dysplastic regenerative nodule in 1 patient (anti-HCV negative). The HCCs were surrounded by cirrhosis (3 cases), chronic active hepatitis (CAH) (n = 2) and post hepatitic fibrosis (n = 1), the cholangiocarcinoma by CAH and the regenerative nodule by cirrhotic liver. Total and replicative intermediate HCV-RNA was analyzed by reverse-transcription-nested PCR of the 5'-untranslated region. The five patients with HCC had HCV-RNA in serum, in tumorous and surrounding liver tissues. The viral nucleic acid was also detected in the cirrhotic tissue surrounding the cholangiocarcinoma but not in the tumor. Two out of 5 HCC patients had replicative intermediate RNA (negative strand) in tumorous tissue, 4 in nontumorous tissue and 3 in serum. These results demonstrate that fine needle biopsy can provide sufficient material for both histological examination and HCV-RNA determination and suggest the existence of continuous viral replication during the carcinogenic process.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

[Diagnosis and course of small hepatocarcinoma in cirrhosis. 6 years' experience]

Diagnosis of hepatocellular carcinoma smaller than 3 cm in diameter was possible in 64 (27.7%) of 231 consecutive cases. Ultrasonography provided the highest diagnostic sensitivity which was further increased by combining this methodology with laparoscopy. Evolution of nodules was more often multicentric but sometimes unicentric with slow growth. Surgical treatment in selected patients (small resections) was associated with high operative mortality (37.5%). Survival of patients (Child C excluded) after percutaneous ethanol injection under ultrasound guidance was 100% at three years.

[Effects of calcium antagonist drugs on glucide metabolism]

The extension of the clinical use of Calcium entry Blockers (CEBs) indicates the need for a careful evaluation of possible adverse effects. Recently, contrasting data have been reported in some studies on the effect of CEBs on oral and i.v. glucose tolerance tests. The aim of the present study was to evaluate the potential diabetogenic properties of CEBs in normal subjects and their activities in diabetic patients. The data present in literature and also personal observations outline the safety of CEBs. In fact, there is a low possibility to derange the balance between insulin and glucagon secretion after acute and chronic administration of CEBs at conventional dosages.

Alpha-fetoprotein Monoclonal Assay: Preliminary Clinical Findings in a High Risk Population

A two-site solid phase immunoradiometric assay was developed for measurement of human alpha-fetoprotein, utilizing two high-affinity monoclonal antibodies directed against distinct and separate epitopes on the proteic structure. The analytical sensitivity of the assay is 0.5 ng/ml. The clinical sensitivity was evaluated by comparison of patients with cirrhosis and patients with hepatocellular carcinoma with cirrhosis. This assay gave good diagnostic discrimination. In a preliminary clinical trial, the specificity of the assay was 92.3%, the clinical sensitivity 88.2%. and predictive values were 78.9% in the clinically positive stage and 96.0% in the negative stage. The diagnostic efficacy of the assay was 91.3%.

[Intrahepatic presinusoidal portal hypertension in a female patient with chronic lymphatic leukemia]

A rare case of intrahepatic presinusoidal portal hypertension, due to massive infiltration of portal zones by chronic lymphatic leukaemia, revealed by sonographic patent umbilical vein, is reported. Sonographic patent umbilical vein which is considered specific for portal hypertension in liver cirrhosis may be present in myeloproliferative syndromes with liver involvement too.