Immunohistochemical analysis of tumour regression grade for rectal cancer after neoadjuvant chemoradiotherapy

AIM

Tumour regression grade (TRG) as defined by Rödel et al. has been used as an independent prognostic factor for rectal carcinoma after preoperative treatment by chemoradiotherapy (CRT). Determination of TRG 2 and 3, semiquantitatively defined as more or less than 50% tumour regression, respectively, does not appear to correlate with prognosis. The purpose of this study was to find an immunohistochemical pattern to permit improved stratification of intermediate responders defined by disease free (DFS) and overall survival (OS).

METHOD

Immunohistochemistry of EGFR (epidermal growth factor receptor), VEGF (vascular endothelial growth factor), CD133 antibody, p53 antibody and Ki67 antibody was evaluated using tissue microarrays (TMA) on post-treatment surgical specimens from 88 patients. CD133 expression was confirmed in the whole section when available.

RESULTS

At a median follow-up of 40 months, TRG was found to be an independent predictor of DFS (P = 0.05) and OS (P = 0.001) but no differences were found between TRG 2 and 3 in terms of DFS (P = 0.74) or OS (P = 0.41). The results of TMA showed an immunohistochemically poor prognostic profile for intermediate responders configured by negativity of CD133 expression. However, when examining CD133 expression in the whole section, there was an intermediate correlation with TMA and the prognostic significance was lost.

CONCLUSION

The results did not confirm the value of immunohistochemistry in predicting the prognosis of patients with rectal cancer following neoadjuvant chemoradiotherapy. This questions the accuracy of TMA in detecting CD133 expression in this setting.

Irinotecan-Cetuximab-Bevacizumab as a Salvage Treatment in Heavily Pretreated Metastatic Colorectal Cancer Patients: A Retrospective Observational Study

<i>Background:</i> The objective was to evaluate the efficacy of irinotecan-cetuximab-bevacizumab in combination as a salvage treatment for heavily pretreated metastatic colorectal cancer patients. <i>Methods:</i> A total of 39 patients resistant to both oxaliplatin and irinotecan were included in this retrospective study. Treatment consisted of irinotecan 180/m² every 14 days, weekly cetuximab standard dose and bevacizumab 5 mg/kg every 14 days. <i>Results:</i> Partial response was observed in 8 patients (20%), stable disease in 24 (61%) and progressive disease in 7 (18%). Overall response rate in KRAS wild type was 6/22 (27%) and in mutated KRAS it was 2/15 (13%). Median time to progression was 8 months (6.4–9.4) and median overall survival 12 months (10.1–13.8). Overall, grade 3–4 adverse events were observed in 24 patients (62%). <i>Conclusions:</i> This regimen is active and moderately well tolerated in heavily pretreated advanced colorectal patients. However, caution is advisable when interpreting these results, because they run against the findings of two large phase III trials.

Phase II study of a fixed dose-rate infusion of gemcitabine associated with erlotinib in advanced pancreatic cancer

PURPOSE

To evaluate the feasibility, toxicity and efficacy of the combination regimen consisting of gemcitabine-FDR infusion plus erlotinib, in ACP patients.

METHODS

Forty-two patients with histologically confirmed, locally advanced or metastatic pancreatic cancer were included in this phase II trial. Main objectives were to assess the efficacy and safety of this regimen. Therapeutic regimen consisted of gemcitabine 1,200 mg/m(2) in 120-min infusion on days 1, 8 and 15, plus erlotinib 100 mg orally once daily. Cycles were repeated every 28 days.

RESULTS

A total of 160 courses of gemcitabine-FDR erlotinib were administered (median 3.8 courses per patient). The most common grade 3-4 AEs were neutropenia (21%), thrombocytopenia (10%), skin rash (10%) and asthenia (10%). Complete response was achieved in one patient (2%) and 11 (26%) achieved a partial response. Stable disease and progression disease were observed in 11 patients (26%) and 19 (45%), respectively. Median time to progression was 5 months (95%CI: 3.9-5.8 months) and median overall survival was 8 months (95% CI: 5.1-10.8). One-year survival rate was 35%.

CONCLUSIONS

A regimen consisting of gemcitabine-FDR infusion plus erlotinib is active and well tolerated in APC patients. However, the results do not justify the conduct of a Phase III trial.

Capecitabine and bevacizumab as first-line treatment in elderly patients with metastatic colorectal cancer

BACKGROUND

The efficacy and safety of capecitabine and bevacizumab in elderly patients with metastatic colorectal cancer (mCRC) considered unsuitable for receiving first-line chemotherapy with an irinotecan or oxaliplatin-based combination were assessed in a phase II, open, multicentre, uncontrolled study.

METHODS

Treatment consisted of capecitabine 1250 mg m(-2) (or 950 mg m(-2) for patients with a creatinine clearance of 30-50 ml min(-1)) twice daily on days 1-14 and bevacizumab (7.5 mg kg(-1)) on day 1 every 3 weeks.

RESULTS

A total of 59 patients aged >or=70 years with mCRC were enrolled. In an intention-to-treat analysis, the overall response rate was 34%, with 71% of patients achieving disease control. Median progression-free survival and overall survival were 10.8 months and 18 months, respectively. In all, 32 patients (54%) had grade 3/4 adverse events (AEs), the most common being hand-foot syndrome (19%), diarrhoea (9%) and deep venous thrombosis (7%). Four patients died because of treatment-related AEs. A relationship was detected between creatinine clearance

CONCLUSION

Bevacizumab combined with capecitabine represents a valid therapeutic alternative in elderly patients considered to be unsuitable for receiving polychemotherapy.

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Key Words

• capecitabine
• bevacizumab
• colorectal neoplasms
• neoplasm metastasis
• aged

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MESH Headings

• Aged
• Aged, 80 and over
• Antibodies, Monoclonal/administration & dosage
• Antibodies, Monoclonal/adverse effects
• Antibodies, Monoclonal, Humanized
• Antineoplastic Combined Chemotherapy Protocols/therapeutic use
• Bevacizumab
• Capecitabine
• Colorectal Neoplasms/drug therapy
• Colorectal Neoplasms/mortality
• Deoxycytidine/administration & dosage
• Deoxycytidine/adverse effects
• Deoxycytidine/analogs & derivatives
• Disease-Free Survival
• Female
• Fluorouracil/administration & dosage
• Fluorouracil/adverse effects
• Fluorouracil/analogs & derivatives
• Humans
• Kaplan-Meier Estimate
• Male

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Concordance of K-Ras status between colorectal cancer (CRC) primaries and related metastatic samples considering clinicopathological features

4053

Background: K-Ras mutations in CRC primaries may predict resistance to anti-epidermal growth factor receptor (EGFR) monoclonal antibodies, but we don´t know its behaviour in metastatic tissue. The aims of this study were: 1) Evaluate the grade of concordance of K-Ras status between primary and related metastatic samples 2) Establish a correlation between k-ras status and individual clinicopathological features Methods: K-ras mutations were retrospectively analysed in primary tumours of 124 patients and 138 related metastatic sites. The primary tumour site was colon in 87 patients and rectum in 37. Sites of metastases were liver (115 samples,83.3%) and lung (23 samples,16.7%). Some patients underwent surgery several times. We analyzed K-Ras point mutations in codons 12 and 13 by direct DNA sequencing from paraffin-embedded tumour and studied its relation with 13 clinicopathological features Results: K-Ras mutation was observed in 42(33.6%) primary tumours and in 52(39.1%) related metastatic sites, being the grade of concordance between primary and metastatic sites of 93% (95% CI: 97.5–88.3%). Discordance was observed in 9 (7%) patients: in 2, K-Ras status was wild type in metastatic site and expressed a mutational pattern in the primary tumour; vice versa, in 7, the mutation status was detected in the metastases meanwhile primary tumour was wild type. We also found statistically significative differences in mutation patterns regarding the site of the metastasic tissue: K-ras mutations were detected in 13 lung samples (61.9%) and in 39 liver samples (34.8%) (p=0.028). Of all the clinicopathological features analyzed we confirmed an increase of mutated K-ras status in tumours which had presented as perforation (p=0.044). No other relation with clinicopathological data was detected Conclusions: With this observational analysis, we confirm the high concordance (superior to 90%) between primary and related metastatic sites in terms of K-Ras status; for the first time, we have reported a higher mutational pattern in lung metastases than in liver disease, founds that may have important relevance regarding clinical/treatment decisions. For the realization of this study we received a grant from Amgen.

No significant financial relationships to disclose.

Phase II study to evaluate the efficacy of capecitabine combined with bevacizumab as first-line treatment in elderly patients with advanced or metastatic colorectal adenocarcinoma

4119

Background: Colorectal adenocarcinoma is the most common cancer in subjects over 70 years old. New therapies have been developed but limited data about their activity are available in elderly population. Results obtained with capecitabine have shown an appropriate safety and efficacy profile in these patients. The aim of the present study is to evaluate the overall response rate in that patient's population who presents colorectal adenocarcinoma and are treated with the combination of capecitabine+BVZ. Methods: This is a multicentric, non-controlled, open label, phase II clinical trial. Capecitabine(1250mg/m2 bid, orally)+BVZ(7.5mg/kg, intravenously) treatment was administered in 3-week length cycles until disease progression. Capecitabine dose was reduced to 1000mg/m2 when the creatinine clearance was between 30 and 50ml/min. Results: A total of 59 patients were included (57.6%, male). Mean age was 76±4.1 years. ECOG status was 0–1 in 96.5 % of the patients. Activities of daily living: moderate to severe dependence and functional incapacity in 24.5% and 5.6% of the patients by Lawton and Barthel scales, respectively. Comorbidities: hypertension (61%), venous thrombosis (5.1%), cardiac disease (5.1%) and acute cerebrovascular accident history (3.4%). Metastases were detected in liver (84.7%), lung (45.8%), local/regional (18.6%) and other locations (5.1%). Mean number of cycles of capecitabine+BVZ was 6.8±6.1. Most frequent grade 3–4 toxicities observed were hand-foot-syndrome (18.6%), diarrhea (8.5%), deep venous thrombosis (6.8%), pain (5.1%) and mucositis (3.4%). Four patients died due to toxicity (mucositis, digestive hemorrhage, hematological toxicity and sepsis, respectively). Metastasis resection was performed in 10.2% of the patients. Treatment response was: 33.3% partial response and 59.0% stable disease. Median progression-free survival was 10.8 months. Conclusions: The combination capecitabine+BVZ in elderly patients appears to have a manageable safety profile and achieves promising results in terms of response rates and progression free-survival.

No significant financial relationships to disclose.

A critical role for choline kinase-alpha in the aggressiveness of bladder carcinomas

Bladder cancer is one of the most common causes of death in industrialized countries. New tumor markers and therapeutic approaches are still needed to improve the management of bladder cancer patients. Choline kinase-alpha (ChoKalpha) is a metabolic enzyme that has a role in cell proliferation and transformation. Inhibitors of ChoKalpha show antitumoral activity and are expected to be introduced soon in clinical trials. This study aims to assess whether ChoKalpha plays a role in the aggressiveness of bladder tumors and constitutes a new approach for bladder cancer treatment. We show here that ChoKalpha is constitutively altered in human bladder tumor cells. Furthermore, in vivo murine models, including an orthotopic model to mimic as much as possible the physiological conditions, revealed that increased levels of ChoKalpha potentiate both tumor formation (P< or =0.0001) and aggressiveness of the disease on different end points (P=0.011). Accordingly, increased levels of ChoKalpha significantly reduce survival of mice with bladder cancer (P=0.05). Finally, treatment with a ChoKalpha-specific inhibitor resulted in a significant inhibition of tumor growth (P=0.02) and in a relevant increase in survival (P=0.03).

Cardiac toxicity: old and new issues in anti-cancer drugs

Although rare, cardiotoxicity is a significant complication of cancer treatment. The incidence and severity of cardiovascular side effects are dependent on the type of drugs used, dose and schedule employed, and age of patients, as well as the presence of coexisting cardiac diseases and previous mediastinal irradiation. Classically, anthracyclines are among one of the most active agents in oncology, but their use is often hampered by their cumulative dose-limiting cardiotoxicity. In the past decade, combination therapy with new drugs such as taxanes or anti- EGFR, and Her-2 therapy as a single agent have also resulted in unexpected cardiotoxicity. Cardiac damage can be secondary to an alteration of cardiac rhythm, changes in blood pressure and ischaemia, and can also alter the ability of the heart to contract and/or relax. The clinical spectrum of these toxicities can range from subclinical abnormalities to being catastrophic, life-threatening and sometimes fatal. Knowledge of this toxicity can aid clinicians to choose the optimal and least toxic regimen suitable for an individual patient. In this work we present an exhaustive review of the cardiovascular side effects associated to new anticancer drugs, from new formulations of anthracyclines to tyrosine kinase inhibitors and monoclonal antibodies.

UFT (tegafur-uracil) in rectal cancer

BACKGROUND

Major achievements in the treatment of localised rectal cancer include the development of total mesorectal excision and the perioperative administration of radiotherapy in combination with continuous infusion (CI) 5-fluorouracil (5-FU). This multimodal approach has resulted in extended survival and lower local relapse rates, with the potential for sphincter-preserving procedures. However, CI 5-FU is inconvenient for patients and is costly. Oral fluoropyrimidines like UFT (tegafur-uracil) offer a number of advantages over 5-FU.

METHODS

We undertook a review of published articles and abstracts relating to clinical studies of UFT in the treatment of locally advanced rectal cancer (LARC). Pre- and postoperative studies carried out in patients with newly diagnosed or recurrent disease were included.

RESULTS

The combination of UFT and radiotherapy was effective and well tolerated in the preoperative setting, while adjuvant UFT improved survival and reduced distant relapse compared with surgery alone. The efficacy of UFT appears comparable with that of 5-FU and capecitabine and its side-effect profile is favourable.

CONCLUSION

Clinical experience to date suggests that UFT is a valuable treatment option for the perioperative treatment of LARC. Further improvements in patient outcomes may result from the combination of UFT with targeted agents.

Phospholipid hydroperoxide glutathione peroxidase (PHGPx) expression is downregulated in poorly differentiated breast invasive ductal carcinoma

Phospholipid Hydroperoxide Glutathione Peroxidase (PHGPx) is the only known enzyme able to reduce lipid peroxides bound to cell membranes. Moreover it has been involved in apoptosis and can influence intracellular signaling. To investigate the possible relationship between PHGPx and human cancer we have quantified PHGPx expression levels by real-time quantitative PCR and immunohistochemistry in tissue samples of human breast invasive ductal carcinoma from 34 patients compared with their own controls of benign breast tissue. PHGPx expression levels were compared with the clinical and pathological data of these patients. The results showed that PHGPx expression levels are downregulated in poorly differentiated (grade 3) breast invasive ductal carcinoma (P = 0.0043). PHGPx expression levels decreased gradually with tumor grade from grade 1 to grade 3. We also found a downregulation of PHGPx in cases that showed p53 accumulation compared with cases without p53 immunostaining (P = 0.0011). PHGPx was also downregulated in cases without progesterone receptors (PR) immunostaining compared with cases with PR immunostaining (P = 0.0165). Grade 3, p53 immunostaining and absence of PR immunostaining are poor prognostic factors. These results suggest that PHGPx downregulation could be related with a poorer prognosis in breast invasive ductal carcinoma.

Biweekly docetaxel (Doc) followed by gemcitabine (Gem) and cisplatin (Cis) in patients (pts) with advanced non-small cell lung cancer (NSCLC): A clinical proteomic study

18096

Background: This phase II trial was carried out to test the feasibility and efficacy of sequential chemotherapy. The scheme was based on the concept of taxane sequencing in cisplatin-based doublet. Finally, we evaluated the predictive value of proteomic profile determined by SELDI-TOF for Doc responses. Methods: Eligible chemonaive stage IV and selected stage IIIB (pleural effusion) NSCLC pts received Doc 50 mg/m2 IV day 1, every 14 days for 4 cycles followed by Gem 1,000 mg/m2 on days 1, 8 and Cis 75 mg/m2 on day 1, every 21 days for 4 cycles. Primary endpoints were response rate and progression-free survival. Overall survival, toxicity and predictive value of the proteomic profile were secondary endpoints. Plasma for proteomic biomarker analysis (SELDI-TOF) was taken at screening and after Doc treatment. Results: From February-05 to December-05, 39 pts were enrolled with 37 being evaluable for efficacy. Pts characteristics: Median Age: 60 years(44–82); Sex: M/F:76%/24%; Stage:IIIB/IV:32%/68%; Performance status 0/1/2:24%/65%/11%; Pathological subtypes: squamous (38%), adenocarcinoma (30%) and large cell carcinoma(32%). 15 pts showed partial response and 1 pt a complete response (objective response rate of 43%) and 14 pts had stable disease (37%). The median survival time (intent-to-treat) was 13 months with an estimated 1-year survival rate of 53%. The median time to progression was 10 months in the evaluable population. Most common grade 3–4 toxicities: After Doc treatment: anemia G3 (2 pts) and asthenia G3 (1 pt); After Gem-Cis: anemia G3 (4 pts), nausea/vomiting G3 (4 pt), neutropenia G3 (4 pts) and asthenia G3 (2 pts). There were no treatment-related deaths. Conclusions: Doc followed by Gem-Cis in sequential setting is an active, feasible and well tolerated regimen. Proteomic profile for Doc responders and no responders will be presented at the time of the meeting.

No significant financial relationships to disclose.

XELOX (capecitabine plus oxaliplatin) as first-line treatment for elderly patients over 70 years of age with advanced colorectal cancer

The purpose of this phase II trial was to determine the efficacy and safety of the XELOX (capecitabine/oxaliplatin) regimen as first-line therapy in the elderly patients with metastatic colorectal cancer (MCRC). A total of 50 patients with MCRC aged > or = 70 years received oxaliplatin 130 mg m(-2) on day 1 followed by oral capecitabine 1000 mg m(-2) twice daily on days 1-14 every 3 weeks. Patients with creatinine clearance 30-50 ml min(-1) received a reduced dose of capecitabine (750 mg m(-2) twice daily). By intent-to-treat analysis, the overall response rate was 36% (95% CI, 28-49%), with three (6%) complete and 15 (30%) partial responses. In total, 18 patients (36%) had stable disease and 14 (28%) progressed. The median times to disease progression and overall survival were 5.8 months (95% CI, 3.9-7.8 months) and 13.2 months (95% CI, 7.6-16.9 months), respectively. Capecitabine was well tolerated: grade 3/4 adverse events were observed in 14 (28%) patients: 11 (22%) diarrhoea, eight (16%) asthenia, seven (14%) nausea/vomiting, three (6%) neutropenia, three (6%) thrombocytopenia, and two (4%) hand-foot syndrome. There was one treatment-related death from diarrhoea and sepsis. In conclusion, XELOX is well tolerated in elderly patients, with respectable efficacy and a meaningful clinical benefit response. Given its ease of administration compared with combinations of oxaliplatin with 5-FU/LV, it represents a good therapeutic option in the elderly.

[Application of European Model of Quality in Oncology]

OBJECTIVES

To assess a Medical Oncology Service using a healthcare setting version of the European Foundation for Quality Management (EFQM). To use this tool as training, an opportunity for participation and the base for checking the strategic planning.

MATERIAL AND METHODS

We use the EFQM Model adapted to healthcare centers EFQM as the evaluation instrument. It maintains scores and weights, only modifying vocabulary and simplifying that not relevant to the healthcare setting. Exercise was done with the "proform" system. Its advantage is that it uses standard formulas combined with open areas for discussion and presentation of ideas. It uses group sessions for agreement.

STUDY PERIOD

2001 Management. Evaluation was performed in the second term of 2002.

RESULTS

58 strengths and 37 areas of improvement were identified. These elements were used to create a strategic document, which served as the basis for future improvement. The score reached was used as an internal reference to monitor service quality evolution.

CONCLUSIONS

The EFQM model is applicable in a Medical Oncology Service, although it would be desirable to have standardized quality indicators that permit a more objective and specific evaluation.

Phase II randomised trial of raltitrexed-oxaliplatin vs raltitrexed-irinotecan as first-line treatment in advanced colorectal cancer

The purpose of this phase II randomised trial was to determine which of two schemes, raltitrexed-irinotecan or raltitrexed-oxaliplatin, offered better activity and less toxicity in patients with advanced colorectal cancer (CRC). A total of 94 patients with previously untreated metastatic CRC were included and randomised to receive raltitrexed 3 mg m⁻² followed by oxaliplatin 130 mg m⁻² on day 1 (arm A), or CPT-11 350 mg m⁻² followed by raltitrexed 3 mg m⁻² (arm B). In both arms treatment was repeated every 3 weeks. Intent-to-treat (ITT) analysis showed an overall response rate of 46% (95% CI, 29.5–57.7%) for arm A, and 34% (95% CI, 19.8–48.4%) for arm B. Median time to progression was 8.2 months for arm A and 8.8 months for arm B. After a median follow-up of 14 months, 69% of patients included in arm A were still alive, compared to 59% of those included in arm B. Overall, 31 patients (65%) experienced some episode of toxicity in arm A and 32 patients (70%) in arm B, usually grade 1–2. The most common toxicity was hepatic, with 29 patients (60%) in arm A and 24 patients (62%) in arm B, and was grade 3–4 in four (8%) and four (9%) patients, respectively. In all, 14 patients (29%) from arm A and 24 patients (52%) from arm B had some grade of diarrhoea (P<0.03). Neurologic toxicity was observed in 31 patients (64%) in arm A, and was grade 3–4 in five patients (10%), while a cholinergic syndrome was detected in nine patients (19%) in arm B. There were no differences in haematologic toxicity. One toxic death (2%) occurred in arm A and three (6.5%) in arm B. In conclusion, both schemes have high efficacy as first-line treatment in metastatic CRC and their total toxicity levels are similar. Regimens with raltitrexed seem a reasonable alternative to fluoropyrimidines.

Localisation of COX-2 protein is different in breast ductal carcinoma and adjacent non-tumour ductal epithelium

INTRODUCTION

A number of findings suggest that cyclooxygenase-2 (COX-2) is overexpressed in breast tumours. However, there is a lack of consensus in the literature regarding the pattern of expression of this protein in invasive breast ductal carcinoma and in the adjacent non-tumour ductal epithelium. This study compares the expression of COX-2 mRNA and protein in breast ductal carcinoma relative to non-tumour breast tissue.

MATERIAL AND METHODS

We analysed the expression of COX-2 mRNA by quantitative PCR, and COX-2 protein by immunohistochemistry in invasive ductal carcinoma as well as in non-tumour adjacent ductal epithelium from 34 breast biopsies diagnosed as being invasive ductal carcinoma. As control, we analysed expression of COX-2 protein by immunohistochemistry in surgically-resected benign breast lesions.

RESULTS

Our results show that COX-2 mRNA and protein are overexpressed in non-tumour ductal epithelium compared with invasive ductal carcinoma. However, the pattern of the protein expression is different in tumour and non-tumour tissue: COX-2 protein is expressed predominantly in the membrane of the non-tumour ductal epithelium (including in benign breast lesions) while, in invasive ductal carcinoma cells, it is localised in the cytoplasm.

CONCLUSIONS

The non-tumour ductal epithelium adjacent to invasive ductal carcinoma shows a higher COX-2 expression than does the invasive ductal carcinoma. However, the different localisation of the immunohistochemically-detected protein suggests a possible post-translational regulation of the protein.

Combination of low-dose cisplatin and gemcitabine for treatment of elderly patients with advanced non-small-cell lung cancer

PURPOSE

To evaluate the feasibility, toxicity and efficacy of the combination of low-dose cisplatin (CDDP) and gemcitabine (GEM) in elderly patients with advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

This phase II trial included 46 patients aged 70 years or older with previously untreated advanced NSCLC. All patients were evaluable for response and toxicity. Treatment consisted of CDDP 50 mg/m(2) on day 1 plus GEM 1000 mg/m(2) on days 1 and 8. The regimen was repeated every 21 days. Patients received a minimum of three courses unless progressive disease was detected.

RESULTS

A total of 190 GEM-CDDP courses were administered (median 4.1 courses per patient). The chemotherapy regimen was well tolerated. No patients developed grade 4 toxicity. Grade 3 toxicities were as follows: neutropenia in six patients (13%), and anemia, thrombopenia and nausea/vomiting in one (2%) each. Two patients (4%) had mild nephrotoxicity. Of the 46 patients, 16 had a partial response (35%, 95% confidence interval, CI, 28-52%), 17 (37%) remained stable and 13 (28%) had disease progression. Eastern Cooperative Oncology Group performance status improved in 17 patients (37%), whereas 25 (54%, 95% CI 44-74%) showed a clinical benefit. Median time to progression was 20 weeks. Overall median survival was 44 weeks, with a 1-year actuarial survival rate of 35%.

CONCLUSIONS

The combination of low-dose CDDP and GEM for elderly patients with advanced NSCLC is an effective and well-tolerated chemotherapeutic approach.

New insights in beta-tubulin sequence analysis in non-small cell lung cancer

Scarce data are available regarding the molecular mechanisms implicated in paclitaxel resistance. There is controversial data about beta-tubulin mutations role in paclitaxel resistance. We have conducted this trial to address the influence of beta-tubulin mutations in paclitaxel resistance in advanced non-small cell lung cancer (NSCLC). A group of 15 patients were biopsied and diagnosed of stages IIIB and IV NSCLC. Tumor specimens were used for DNA isolation and exon 4 of HM40 beta-tubulin isotype was amplified and automatically sequenced, using both intronic and exonic primers. Next, the chemotherapy schedule consisted of weekly paclitaxel (100 or 150 mg/m(2) x 6) followed 2 weeks later by cisplatin 100 mg/m(2) on day 1, gemcitabine 1000 mg/m(2) on days 1 and 14, and vinorelbine 25 mg/m(2) on days 1 and 14, every 28 days. Using exonic primers, gene sequence alterations were found in 13/15 (87%) patients, including transitions (codons 180 and 182) and one silent transversion (codon 195). Also, three transversions (codons 231, 234, and 235) were found in all patients and controls. All alterations disappeared when sequenced with intronic primers. Our results suggest that point mutations demonstrated with exonic primers but not with intronic ones are probably due to beta-tubulin pseudogenes present in advanced NSCLC specimens. Even so, when these beta-tubulin pseudogenes are found there is a clear relation with clinical response. Although these changes could be relevant in paclitaxel resistance, this observation must be proven in future clinical trials to resolve "the tubulin dilemma".

Correlation of p53 oncoprotein expression with chemotherapy response in small cell lung carcinomas

p53 oncoprotein expression was investigated in small cell lung carcinomas (SCLC) using immunohistochemical staining with antibodies against p53. A total of 50 pre-treatment biopsies were examined. We analyzed the relationship between p53 expression and these patients' relevant clinical characteristics, response to chemotherapy, time to progression, and overall survival. We found p53 overexpression in 46% of the samples but no association with clinical data or overall survival. Our results show a strong correlation of p53 staining with chemotherapy response. Multivariate analysis selected p53 as an independent predictive factor of chemotherapy response.

Beta-catenin expression pattern in small cell lung cancer: correlation with clinical and evolutive features

Beta-catenin expression in small cell lung carcinomas (SCLC) was investigated by immunohistochemical method using antibodies against beta-catenin. 50 pre-treatment biopsies were examined and the relationship between beta-catenin expression and the patients' relevant clinical characteristics, response to chemotherapy, time to relapse or progression, and overall survival, were analyzed. Beta-catenin expression exhibited different intensity within each sample, predominantly localized in the cytoplasm, and no sample showed nuclear expression. There was cytoplasmic hyperexpression in 14 cases, hypoexpression in 15 cases, and normal expression in 21 cases. We did not find any association between beta-catenin expression and clinical data. Our results show, however, correlation between beta-catenin cytoplasmic hyperexpression with a shorter time to progression (p=0.0437) as well as with a shorter overall survival (p=0.0253). Beta-catenin hyperexpression could have prognostic significance in SCLC.

beta-catenin expression pattern in primary oesophageal squamous cell carcinoma. Relationship with clinicopathologic features and clinical outcome

beta-Catenin has an essential role in intercellular adhesion and signal transduction. beta-catenin functions as a transcriptional activator downstream in the Wnt signalling pathway. Cytoplasmic stabilisation of beta-catenin, mainly due to inactivating mutations of the adenomatous polyposis coli (APC) tumour suppressor gene or activating mutations in exon 3 of the beta-catenin gene, can activate this important pathway in the development of several carcinomas. To determine whether this pathway for malignant transformation is important in oesophageal cancer, we analysed 39 primary oesophageal squamous cell carcinomas (OSCC). Immunohistochemical expression of beta-catenin was studied in formalin-fixed, paraffin-embedded tissue samples. Results were correlated with clinicopathological parameters and immunohistochemical expression of the proteins p53, E-cadherin, bcl-2 and Ki-67. All examined OSCC had beta-catenin expression localised in the cellular membrane, frequently with a heterogeneous pattern. Seven (18%) cases also showed immunoexpression in the cytoplasm and nuclei of the tumour cells. These seven tumours were localised in the upper (three) or in the middle third (four) of the oesophagus. Only one patient had p53 expression and all had bcl-2 expression. The consensus sequence for glycogen synthase kinase (GSK) 3beta phosphorylation in exon 3 of the beta-catenin gene was studied using polymerase chain reaction and direct sequencing in the seven cases with nuclear beta-catenin expression. No genetic alteration was found. These results suggest that beta-catenin expression may characterise a subset of OSCC.

Pregnancy in a breast cancer patient treated with a LHRH analogue at ablative doses

A 36-year-old female diagnosed of breast cancer was treated with surgery, chemotherapy, radiotherapy and goserelin. After 17 months of uninterrupted therapy with this LHRH analogue at hormone suppressive doses, a 16-week gestation foetus was detected and the treatment was withdrawn. Although the drug was administered throughout the first 4 months of pregnancy it resulted in the term delivery of a healthy infant, and no foetal adverse effects were detected. A review of the influence of hormonal treatment for breast cancer on fertility and birth defects has been performed.

Circulating cancer cells in peripheral blood. A case report

BACKGROUND

Carcinocythemia, the presence of circulating cancer cells in peripheral blood, is a rare complication of solid neoplasms. When the number of such cells is very high, they can be detected during routine laboratory tests. They are associated with a dismal prognosis.

CASE REPORT

Carcinocythemia occurred in a patient with disseminated breast cancer. Eighteen cases were identified from a review of the literature. The most common neoplasms associated with circulating cancer cells in peripheral blood were breast adenocarcinoma, small cell lung carcinoma and rhabdomyosarcoma. All the patients had stage IV disease at the time of diagnosis, and all had involvement of the reticuloendothelial system. Patients survived for an average of a few days or weeks.

CONCLUSION

Circulating cancer cells in peripheral blood are an unusual manifestation of disseminated neoplasms that occurs as a terminal event.

Failure of goserelin ovarian ablation in premenopausal women with breast cancer: two case reports

OBJECTIVE

We hereby report on two patients receiving goserelin due to breast cancer in whom a failure in ovarian ablation was detected. A review of the hormonal effects of LHRH analogues is performed.

CASE REPORTS

CASE 1: A 36-year-old female was diagnosed with breast carcinoma and treated with surgery, chemotherapy, radiotherapy, and goserelin. A 16-week gestation was detected after 17 months of uninterrumpted hormonal therapy at ablative doses. CASE 2: A 41-year-old female was diagnosed with breast carcinoma and treated with surgery, chemotherapy, radiotherapy, and tamoxifen. Goserelin was substituted for tamoxifen due to bone metastases and, 2 years later, a failure in ovarian ablation was confirmed after the reappearance of the patient's menses.

CONCLUSIONS

Goserelin-induced ovarian ablation may fail after the use of appropriate doses of this drug. We suggest a possible mechanism of hormone resistance induced by the long-term administration of LHRH analogues. No fetal damage was detected after goserelin exposure in the first 4 months of gestation.

Efficacy of oral tegafur modulation by uracil and leucovorin in advanced colorectal cancer. A phase II study

A phase II study was performed to assess the efficacy and toxicity of UFT (tegafur-uracil in the molar ratio 1:4) modulated with leucovorin (LV) in previously untreated patients with advanced colorectal carcinoma (CRC). 79 patients with measurable advanced colorectal cancer (CRC) and no prior chemotherapy were included. 75 patients were evaluable for toxicity and response. The regimen consisted of LV 500 mg/m2 administered intravenously on day 1, followed by oral UFT 390 mg/m2 on days 1-14. Patients received oral LV 15 mg every 12 h on days 2-14. Treatment was repeated every 28 days for a minimum of four courses per patient. Three hundred and ninety-eight cycles of chemotherapy were delivered (median five per patient). 7 patients (9%) had a complete response, and 22 a partial response for an overall response rate of 39%. Mild gastrointestinal toxicity was dose limiting: grade 3-4 diarrhoea appeared in 9% of patients. Other grade 3-4 toxicities were nausea/vomiting and mucositis in 4% of patients, gastric pain and leucopenia in 3%. Oral UFT modulated by oral LV is active in advanced CRC and can be administered on an outpatient basis with no significant toxicity requiring hospitalisation. Given its excellent tolerance profile and low toxicity, the regimen should be thoroughly studied and compared with 5-fluorouracil modulated by LV.

Single-centre experience of peripheral blood stem cell transplantation using cryopreservation by immersion in a methanol bath

A simplified method to remove and cryopreserve peripheral blood stem cells (PBSC) was utilised to restore the bone marrow in 31 patients with haematological or solid neoplasms after ablative chemotherapy. Mobilization was performed with subcutaneous G-CSF, starting 4 days before the first PBSC harvest and continuing to the last day of harvest. Cryopreservation was carried out by freezing cells to -80 degrees C after addition of autologous fresh plasma with DMSO, in a methanol bath and non-programmed freezer. The PBSC were reinfused in all cases. The mean quantity of CD34 cell (x 10(6)/kg) infused was 6.5 +/- 6.7. The mean number of procedures needed to harvest an appropriate number of PBSC was 3.6 +/- 1.3. The mean times necessary to recover more than 0.5 x 10(9)/l granulocytes were 11 +/- 4 (8-30) days and 23 +/- 13 (8-55) days to obtain more than 20 x 10(9)/l platelets. These results confirm our method as very effective in achieving a high-quality harvest, and it was used in paediatric and adult patients without problems. This procedure, using a non-programmed freezer, simplifies and reduces enormously the cost of the technical measures currently used, enabling their adoption in almost any clinical oncological institution.

Treatment of advanced gastric cancer with the combination fluorouracil, leucovorin, etoposide, and cisplatin: a phase II study of the ONCOPAZ Cooperative Group

A phase II study was performed to assess the efficacy and toxicity of the combination of 5-fluorouracil (5-FU), leucovorin (LV), etoposide, and cisplatin (FLEP) in patients with advanced gastric carcinoma. A total of 46 consecutive, previously untreated patients with unresectable, measurable gastric carcinoma were treated with 300 mg/m2 LV, 100 mg/m2 etoposide, 500 mg/m2 5-FU, and 30 mg/m2 cisplatin on days 1-3 every 28 days. All courses were given on an outpatient basis. A total of 169 courses of treatment were given. In all, 18 of the 46 patients (39%) had an objective response [95% confidence interval (CI), 25%-54%] and 2 (4%) patients experienced a clinical complete response. The median duration of response was 5 months. The main side effects were hematological and gastrointestinal. Grade 3-4 toxicity was encountered as follows: leukopenia, in 9.5% of the courses; anemia, in 3%; thrombocytopenia, in 3%; nausea/vomiting, in 4%; and diarrhea, in 5%. Hospitalization due to fever and granulocytopenia was required in 5 patients, 3 of whom died of sepsis. In conclusion, FLEP shows moderate activity in patients with advanced gastric carcinoma, albeit at the cost of a high degree of toxicity. For this reason we do not recommend its use.

Usefulness of megestrol acetate in cancer cachexia and anorexia. A placebo-controlled study

To assess the effect of megestrol acetate (MA) on the appetite and weight of cancer patients with nonhormone-dependent tumors, a double-blind, placebo-controlled trial was designed. One hundred fifty patients were included: 76 were given MA (240 mg/day orally) for at least 2 months, and 74 were given placebo (P). Body weight, subjective sense of appetite (SSA) evaluated by an analogic linear visual scale scored from 1 to 10, and performance status (PS) were measured before therapy and monthly thereafter. No differences in body weight before and after treatment could be found in any group. However, 32% of the patients in the MA group (95% confidence interval: 20.1-44.6%) gained 2 or more kilograms (P less than 0.001). This group also showed an improvement in SSA (P less than 0.01): an increase greater than or equal to 2 points appeared in 57.5% of patients (95% confidence interval 44.6-69.4%). There was no significant difference in PS for the treatment groups before or after therapy. The percentage of reported adverse events did not differ significantly from one treatment group to the next. We conclude that therapy with MA at a dose of 240 mg/day improved SSA and was associated with moderate weight gain in patients with hormone-insensitive malignancies.

[Hemostasis and cancer]

It is well known that patients with neoplasms have a greater incidence of thrombosis and bleeding episodes. Many are the analytic alterations observed and there are many works on the possible pathophysiologic mechanisms which support them as well as their importance in the process of metastasis: fibrinolytic activation, tumor coagulability and aggregability; inflammatory-immune system; tumoral neovascularization and the liberation of specific tumor substances. This paper is a bibliographic review of the role of these mechanisms giving the best possible unified outlook.