Role of radiotherapy in neuroblastoma

Clinical Development of new Fluoropyrimidines: A Major Improvement in Colorectal Cancer Treatment?

Aims and background

Colorectal cancer represents an increasing problem and is responsible for about 16,000 deaths per year in Italy. Fluorouracil represents the most widely used agent, but therapeutic responses have remained consistently discouraging. The overall response rates for fluorouracil as a single agent range from 5% to 15%, and the addition of biochemical modulators, although able to improve response rate, has not been shown conclusively to prolong survival.

Methods

In recent years, several new compounds characterized by a high therapeutic index, optimal absorption through the gastrointestinal tract when administered orally and selective hepatic metabolization have been synthesised. In this review we analyzed published data on new fluoropyrimidines in an attempt to better define their role and to evaluate any significant improvement over fluorouracil.

Results

Athough no sure advantage over fluorouracil has been detected, interesting results have been reported for fluorouracil analogs with alternative routes of administration such as oral or intra-arterial chemotherapy.

Conclusions

Further studies, possibly randomized, should also measure quality of life and treatment-related costs in order to define their real advantage over fluorouracil in the palliation of advanced colorectal cancer.

Retrospective comparative analysis of 5FU + low-dose folinic acid vs. 5FU + high-dose folinic acid in the treatment of metastatic colorectal cancer. The Ottawa experience

Two regimens of 5FU and folinic acid in the treatment of metastatic colorectal cancer were retrospectively analyzed. 33 patients received the high dose (HD) schedule (5FU 370 mg/m2 and Folinic Acid 200 mg/m2 i.v. on D1-5, every 4 weeks), 61 patients received the low dose (LD) schedule (5FU 400 mg/m2 and Folinic Acid 20 mg/m2 i.v. on D1-5, every 4 weeks). One patient in each group achieved a complete response, the overall response rate was 28% and 11% for the HD and LD groups, respectively. The median response duration was 183 days for the HD and 112 days for the LD group. The median survival duration was 387 days for the HD and 405 days for the LD group. The response rate and duration of response were higher in the HD group though this did not reach statistical significance. There was no difference in overall survival between the two patient groups. Neutropenia and gastro-intestinal symptoms were the most common toxicities, they were equal in both groups. One patient (3%) in the HD and 5 patients (9%) in LD group discontinued treatment due to toxicity. There were no treatment related deaths. It is concluded that low dose folinic acid in combination with 5FU is effective and produces similar toxicities as high dose folinic acid. It is concluded that low dose folinic acid in combination with 5FU is an effective alternative to high dose regimen in the palliative management of patients with metastatic colorectal cancer. However though it did not reach statistical significance the high dose regimen was associated with a higher response rate. This could have a significant effect when the combination is used in the adjuvant treatment of high risk patients.

Long-term results of therapy for stage C neuroblastoma

BACKGROUND

The appropriate therapy for Stage C neuroblastoma (NB) is uncertain. Because of the need for information applicable to the development of new randomized trials, we deemed it appropriate to investigate the patient characteristics, survival, patterns of failure, and complications of therapy in these children.

METHODS

Search of the medical records of Duke University Medical Center from 1/1/60 to 3/1/95 disclosed 146 patients with NB, which included 13 Stage C patients.

RESULTS

Mean age at diagnosis was 3.6 years. Twelve patients had primary abdominal tumors (92%) and one had a thoracic primary (8%). Twelve (92%) of the patients received chemotherapy including cyclophosphamide. 11 (85%). Adriamycin, 6 (46%), cisplatinum, 4 (30%), and VP 16, 4 (30%). All patients received radiotherapy (RT, mean dose administered 22.6 +/- 8 Gy). With a mean follow-up of 8 years, the 10-year overall survival was 54% and the relapse-free survival was 46%. Four patients relapsed in the primary operative tumor bed and primary RT field, two relapsed in mediastinal or left supraclavicular lymph nodes as well as distantly following treatment of upper abdominal primaries, and in one the site of relapse is unknown. Long-term complications of therapy included two children who developed secondary malignancies associated with RT, two girls who developed primary ovarian failure, five children with clinically significant kyphosis and scoliosis, and one who suffered postoperative wound dehiscence following RT.

CONCLUSIONS

Although this study did not include modern techniques of staging with n-myc amplification and DNA index, the occurrence of next echelon nodal failures gives credence to the continuation of the dialogue concerning the appropriate role of "prophylactic" irradiation to mediastinal and left supraclavicular nodes in locally advanced upper abdominal NB. Documentation of significant long-term ill effects reinforces the need to critically evaluate the indications for RT.

Wilms' tumor: the Northern Israel Oncology Institute experience

Between 1971 and 1992, 42 children (median age = 2 years) with histologically proven Wilms' tumor were evaluated at the Northern Israel Oncology Institute. Most patients were staged according to National Wilms' Tumor Study (NWTS) criteria by which 18 were clinical stage I-II and 24 were III-IV. Combined therapy (surgery, chemotherapy, and radiotherapy) was given with a change to lower dose radiotherapy (< 2,000 cG) after 1981. The pre-1981 group (13 patients) suffered six relapses, most of which were pulmonary, whereas the 1981-1992 group (29 patients) had three relapses. The actuarial 5-year survival rate using Kaplan-Meier tables was 79% for the entire group but 100% for the 1981-1992 group and 38% for the 1971-1980 group. One case of immediate hepatic toxicity and one sudden death, unknown cause, of a patient in remission occurred in the group. Late deleterious effects were seen in five other patients; four had scoliosis and one developed osteoid osteoma of a rib. Despite these encouraging results, the necessity of ongoing monitoring for further long-term toxicities is apparent.

Wilms' tumor: a rational use of preoperative imaging

OBJECTIVE

To determine whether a preoperative imaging protocol relying predominantly on a chest X-ray film (CXR) and ultrasound in patients with Wilms' tumor is adequate for patient management and to determine the frequency more sophisticated imaging, in particular, computed tomography (CT), is required.

DESIGN AND SETTING

Historical cohort study at a tertiary pediatric hospital.

SUBJECTS

60 consecutive patients with Wilms' tumor treated at our institution between 1980 and 1990.

MAIN OUTCOME MEASURE

The preoperative imaging was recorded and 2- and 4-year survival were compared with the National Wilms' Tumor Study.

RESULTS

100% of patients had a preoperative CXR, 95% abdominal ultrasound, 5% abdominal CT, 13% chest CT, 47% abdominal X-ray, 2% aortography, 5% cavography, and 35% intravenous urography. The overall 2- and 4-year survivals of 92% and 90%, respectively, did not statistically differ from the National Wilms' Tumor Study 2- and 4-year survivals of 94% and 91%.

CONCLUSIONS

A preoperative imaging protocol relying predominantly on a CXR and abdominal ultrasound does not reduce survival. Other more sophisticated imaging, in particular, CT, is not required in the majority of cases and is warranted only when a CXR or ultrasound is unable to resolve relevant management problems.