Preoperative chemotherapy for T2 breast cancer is associated with improved surgical outcome

BACKGROUND

The aim of this study is to compare the clinical outcome in T2 breast cancer patients who underwent preoperative chemotherapy (PC) and who did not. The study also tried to define a subgroup of patients, who are more beneficial after PC in terms of lower re-excision rates, better cosmetic results and local recurrence free survival.

MATERIALS AND METHODS

251 consecutive patients treated for nonmetastatic T2 invasive breast cancer were analyzed retrospectively. Of those; 141 underwent primary surgery (PS) followed by chemotherapy, whereas 110 were treated with combination of PC and surgery.

RESULTS

The patients who were treated with PC had a significantly higher incidence of negative margins and lower rate of re-excision (5% vs. 16%, p = 0.02). Of all patients attempted breast conserving surgery (BCS), patients in the PC group were more likely to undergo BCS as their definitive operation compared to patients with PS group (BCS rates; PC group: 99% vs. PS group: 92%, p = 0.05). Multifocal disease (OR: 7, 95% Cl, 2.7-18.4, p = 0.0001) and PC (OR = 0.2; 95% CI, 0.06-0.72, p = 0.01) were factors associated with margin positivity in patients treated with BCS. There was no statistically significant difference in 5 year local-recurrence free survival rates between 2 groups.

CONCLUSIONS

Our study shows that PC significantly decreases the re-excision in patients undergoing BCS with primary T2 breast tumors. This data suggests that any patient with a tumor greater than 2 cm might be considered for PC to increase BCS success with final negative margins.

Is there any diagnostic value of serum protease-activated receptor-1 (PAR1) levels on determination of epithelial ovarian carcinoma?

The role of molecular markers in ovarian cancer is still a matter of debate. Protease-activated receptor-1 (PAR1) might be a good marker in some types of malignant tumors and might provide useful information in diagnosis and prognosis. The objective of this study was to evaluate the serum levels of PAR1 in regard to diagnostic, predictive, and prognostic value in epithelial ovarian cancer (EOC) patients. Forty-four EOC patients were enrolled in this study. Serum PAR1 levels were determined by enzyme-linked immunosorbent assay (ELISA) method. Twenty-five age- and sex-matched healthy controls were included in the analysis. The median age of patients was 58 years old, ranging from 22 to 83 years, where most of them had advanced disease (stage III-IV) (n = 40, 91%). The median serum PAR1 values were significantly elevated in patients compared to healthy controls (1.52 ng/ml vs. 1.13 ng/ml) (p = 0.03), whereas any clinical variables including response to chemotherapy did not associate with serum assay (p > 0.05). Progression-free survival (PFS) and overall survival (OS) of patients who did not respond to chemotherapy nor had platinum resistance in relapsed disease were poorer in the analyses. On the other hand, serum PAR1 levels showed no significant adverse effect on either PFS or OS (p = 0.43 and p = 0.49, respectively). These results proved that baseline serum PAR1 levels of patients with EOC were significantly higher than those of healthy people. However, these assays suggested no predictive or prognostic value in this group of patients.

Abstract P1-01-22: Which cytologically proven node-positive breast cancer patients can avoid axillary lymph dissection after neaodjuvant chemotherapy?

BACKGROUND:

It is still controversial whether axillary lymph node dissection can be omitted after negative sentinel lymph node biopsy in breast cancer patients with clinically positive axilla at presentation treated with neoadjuvant chemotherapy (NAC). The aim of this study was to analyze whether SLN biopsy could be useful in these patients.

METHODS:

After NAC of 112 patients with cytology-proven axillary node metastasis at the time of diagnosis, SLNB using radioisotope and blue dye was performed including completion node dissection between 2008 and 2012. The results of SLNB and clinicopathological characteristics were analyzed for correlation with pathological axillary lymph node status.

RESULTS:

SLN was successfully identified in 107 (95.5%) patients. Tumor nonresponse and extensive residual nodal disease were found to be significantly associated with detection failure of sentinel nodes. Axillary status was predicted with 94% accuracy and a false negative rate of 8.7%. Axillary nodal status before NAC (cN2 versus cN12) was associated with higher false-negative rates (p = 0.02). Conversion to node-negative disease was achieved in 38 (35%) patients: 23% of patients with the luminal A subtype, 12% of patients with the luminal B, 39% of patients with the HER2-enriched, and 26% of patients with the triple-negative breast cancer subtype. The tripple negative and HER2-enriched breast cancer subtypes had a significantly better false negative rate and accuracy.

CONCLUSIONS:

SLNB was found to be technically feasible, but its routine use was not recommended for LABCs after NAC. However, acceptable performance was noted for tripple negative and HER2-enriched breast cancer patients presented with N1 axillary status in the beginning of NAC, and thus SLNB might be safely considered in these selected patients.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-01-22.

Detection of human papillomavirus DNA by polymerase chain reaction and southern blot hybridization in colorectal cancer patients

PURPOSE

The molecular mechanisms related to colorectal carcinogenesis are controversial. The purpose of this study was to evaluate the possible role of high-risk oncogenic human papillomavirus (HPV) types in the pathogenesis of colorectal cancer.

PATIENTS AND METHODS

Tumor, and corresponding normal mucosal tissue specimens were obtained soon after surgery from 56 patients with colorectal adenocarcinoma. We studied both neoplastic and normal colon tissues for the presence of HPV types 6, 11, 16, 18, and 33. After the isolation of DNA, the presence of specific types of HPV DNA was determined by polymerase chain reaction (PCR) and southern blot hybridization.

RESULTS

HPV DNA was detected in 46 (82.14 %) of 56 colorectal adenocarcinomas and in 18 (32 %) of 56 normal colonic mucosal tissue samples. Two or more HPV types were detected in 32 carcinoma samples. HPV type 18 (n= 40) and 33 (n= 32) were the most frequently detected types of HPVs in the tumor tissues. None of the normal mucosal specimens revealed HPV 18 DNA. The expression rate of HPV DNA in tumor tissue was significantly higher than that encountered in normal colonic mucosa (p <0.001).

CONCLUSION

Detection of HPV DNA types 18 and 33 in most of the colorectal adenocarcinoma specimens suggests that HPVs may be related to carcinogenesis in glandular cells of the colorectal mucosa of our patient population.

Effect of oral administration of kefir on serum proinflammatory cytokines on 5-FU induced oral mucositis in patients with colorectal cancer

In order to investigate the effect of kefir consumption on mucositis induced by 5-FU based chemotherapy (CT), we monitored the systemic immune response by measurement of the serum proinflammatory cytokine levels and we evaluated the anti-microbial effect of kefir with an agar diffusion method. Forty patients with colorectal cancer were included in this randomized prospective study. On the first 5 days of each CT cycle, the study group received oral lavage with kefir and then swallowed 250 ml of kefir while control group received oral lavage with 0.09% NaCl twice a day. Before and after every cycle of CT, the oral mucosa was assessed. Serum proinflammatory cytokine levels were evaluated before the initiation and after the third and the sixth cycle. Kefir was administered in 99 out of 205 courses. Mucositis developed in 27.3% of the courses given with kefir administration and in 21.7% of the courses given with 0.9% NaCl oral rinses. The difference between the two groups was not statistically significant (p > 0.05). When we compared the serum proinflammatory cytokine levels of the two groups at the baseline and following the third and the sixth cycles, we again found no statistically significant difference (p > 0.05). Kefir consumption at the mentioned doses made no statistically significant effect on serum proinflammatory cytokine levels and on the incidence of mucositis development in cancer patients. Under in vitro conditions, kefir inhibits only Staphylococcus epidermidis.

Isolated lung perfusion with Paclitaxel and docetaxel: comparison of the early effects on pulmonary physiology

BACKGROUND

This study was designed to compare the early effects of docetaxel and paclitaxel on pulmonary physiology after isolated lung perfusion.

METHODS

Rats underwent isolated left lung perfusion with docetaxel in group 1 (n = 5), paclitaxel in group 2 (n = 5), and 0.9 %NaCl in the control group (n = 5). Ventilation pressures, compliance of the lungs, blood gas analysis and histopathological results were compared between the groups.

RESULTS

In group 1 and group 2, the decrease in PaO (2) (p = 0.008) and increase in ventilation pressures were significantly higher than in the control group ( P = 0.016). In group 2, pCO (2) retention was higher compared to the docetaxel perfusion group ( P = 0.016). In the histochemical assessment, intra-alveolar hemorrhage and mononuclear cell infiltration were dense and perivascular edema was not present in group 1. In group 2, perivascular and intraalveolar edema were found to be dense.

CONCLUSION

Perfusion by either of the chemotherapeutics resulted in an alteration of lung physiology in rat lungs. If isolated lung perfusion is administered using chemotherapeutics from the taxanes group, it is suggested that docetaxel could be the first choice for isolated lung perfusion.

Efficacy of cisplatin and cyclophosphamide combination for recurrent and metastatic carcinoma of the uterine cervix

The efficacy of a combination of cyclophosphamide and cisplatin in patients with metastatic and recurrent carcinoma of the cervix, was tested. Thirty patients were included in the study. Initially, 27 patients (90%) had received pelvic radiation and intracavitary boost and one patient was additionally given paraaortic radiation. Cisplatin was given at 75 mg/m2 followed by cyclophosphamide at 750 mg/m2 on day 1 with three weekly intervals for a maximum of six cycles. All patients received a median of four cycles of chemotherapy. The overall response rate for all eligible patients was 20% (continuous CR: 1, CR: 1, PR: 4 patients). Overall response rate and progressive response in patients with relapse within the previous radiation field were 9.5% and 66.7%, respectively; while for patients who had recurrent disease outside any irradiated area both were 44.4%. Eighteen patients (60%) had early withdrawal from the planned schedule, which was due to patient incompliance in seven patients (23.3%), disease progression in ten (33.3%) and early death after the first cycle in one patient (3.3%). Anemia was the most frequent toxicity, necessiating 24 transfusions in nine patients (30%). WHO grade 3 and 4 toxicity were anemia: 13 (43.3%), leucopenia: one (3.3%), thrombocytopenia: two (6.6%), renal: one, emesis: nine (30.0%) patients. The median survival duration for all eligible patients was 11 months. Univariate analysis revealed that progressive response to chemotherapy was the only prognostic factor for survival (7.1 vs 16.8 months, p = 0.003). The combination of cisplatin and cyclophosphamide did not appear to be more active than single agent cisplatin in this patient group with a relatively poor prognosis. Further studies are required to determine a better therapeutic approach for patients with relapsed carcinoma of the cervix.

Prognostic factors and survival in patients with metastatic or recurrent carcinoma of the uterine cervix

The aim of this study is to identify the impact of various prognostic factors on survival in patients with recurrent carcinoma of the uterine cervix. Fifty-two patients who were treated with platinum-based chemotherapy for recurrent or metastatic disease were retrospectively evaluated. Twenty-seven patients (90%) had received pelvic radiation as primary treatment. Out of 45 evaluable patients, two (4.4%) had complete response (CR), three (6.7%) had a continuous CR after additional surgical treatment and irradiation. Five patients (11.1%) had partial response (PR). The majority of patients had progressive response to treatment (22 patients, 48.9%). After a median follow-up period of 19 months, 31 patients (60%) had died. Progression-free survival after initial diagnosis was observed to have a significant association with response to chemotherapy for recurrent disease (Fisher two-sided P = 0.027). The median survival duration for relapsed disease was 11.8 months. Those with a longer disease-free interval ( 8 months vs. </= 8 months) from initial diagnosis to first recurrence and response to chemotherapy had a tendency for a longer survival duration after relapse by univariate analysis. Multivariate analysis revealed that progressive response to chemotherapy (P = 0.002, HR = 4.6) and recurrence within the previously irradiated field (P = 0.04, HR = 2.7) were significant independent prognostic factors for a shorter time to progression after recurrence. Furthermore, advanced stage at presentation (P = 0.001, HR = 3.0) and a short disease-free interval after primary treatment (<8 months, P = 0.003, HR = 3.4) were determined as independent prognostic factors with a significant negative influence on progression-free survival and overall survival from initial diagnosis, respectively. The use of toxic and expensive combinations for the treatment of recurrent cervical cancer patients should be well balanced against potential hazards. Based on our data, less toxic regimens would be more feasible in patients who present with advanced disease at initial diagnosis, or those that experience recurrence within the previously irradiated field after a progression-free interval of less than 8 months.

Prognostic factors and survival in patients with metastatic or recurrent carcinoma of the uterine cervix

The aim of this study is to identify the impact of various prognostic factors on survival in patients with recurrent carcinoma of the uterine cervix. Fifty-two patients who were treated with platinum-based chemotherapy for recurrent or metastatic disease were retrospectively evaluated. Twenty-seven patients (90%) had received pelvic radiation as primary treatment.

Out of 45 evaluable patients, two (4.4%) had complete response (CR), three (6.7%) had a continuous CR after additional surgical treatment and irradiation. Five patients (11.1%) had partial response (PR). The majority of patients had progressive response to treatment (22 patients, 48.9%). After a median follow-up period of 19 months, 31 patients (60%) had died. Progression-free survival after initial diagnosis was observed to have a significant association with response to chemotherapy for recurrent disease (Fisher two-sided P = 0.027). The median survival duration for relapsed disease was 11.8 months. Those with a longer disease-free interval (8 months vs. ≤ 8 months) from initial diagnosis to first recurrence and reponse to chemotherapy had a tendency for a longer survival duration after relapse by univariate analysis. Multivariate analysis revealed that progressive response to chemotherapy (P = 0.002, HR = 4.6) and recurrence within the previously irradiated field (P = 0.04, HR = 2.7) were significant independent prognostic factors for a shorter time to progression after recurrence. Furthermore, advanced stage at presentation (P = 0.001, HR = 3.0) and a short disease-free interval after primary treatment (<8 months, P = 0.003, HR = 3.4) were determined as independent prognostic factors with a significant negative influence on progression-free survival and overall survival from initial diagnosis, respectively.

The use of toxic and expensive combinations for the treatment of recurrent cervical cancer patients should be well balanced against potential hazards. Based on our data, less toxic regimens would be more feasible in patients who present with advanced disease at initial diagnosis, or those that experience recurrence within the previously irradiated field after a progression-free interval of less than 8 months.

Combination chemotherapy with docetaxel and irinotecan in metastatic malignant melanoma

AIM

The aim of the current trial was to assess the efficacy and toxicity of 3-weekly intravenous docetaxel and irinotecan in the treatment of patients with metastatic malignant melanoma.

MATERIALS AND METHODS

Sixteen patients with no history of previous cytotoxic agents or immunological treatment for advanced disease were treated with docetaxel 50 mg/m2 and irinotecan 150 mg/m2 intravenously over 60 min every 21 days. Prior immunotherapy with interferon and chemotherapy for adjuvant therapies were accepted provided there was a minimum 4-week treatment-free interval. Response evaluation was performed after two cycles.

RESULTS

None of the patients had chemotherapy-induced tumour response. Eight patients achieved stable disease and others had progression of disease. The median survival time was 136 days (95% CI: 30.2-241.8), and the 3-month survival rate was 62.5%. Patients with stable disease (n = 8) had a longer survival than non-responders (P = 0.023, Breslow test). Generally side effects were mild and tolerable. Grade III-IV haematological toxicity occurred in approximately 10%. Severe emesis, stomatitis and diarrhoea was seen in less than 20% of the patients. Alopecia was observed in all patients.

CONCLUSION

A 3-weekly intravenous docetaxel and irinotecan combination appears to be inactive in the treatment of patients with malignant melanoma and has not been recommended.

An atypical presentation of metastatic gestational choriocarcinoma with maxillary sinus and subcutaneous involvement; report of a case with literature review

Extragonadal germ cell tumors are rare neoplasms with histologic features comparable to those of gonadal origin. In this case report we present a 21-year-old female patient with an atypical localization of metastatic gestational choriocarcinoma. She was admitted to our hospital with recurrent epistaxis, abnormal vaginal bleeding, rectal bleeding, subcutaneous nodules on both thighs and forearms and left maxillary mass with intranasal cavity invasion. Laboratory analysis revealed significant elevation in serum beta-human chorionic gonodotropin (beta-HCG) level. Abdominal computerized tomography (CT) revealed left renal and retroperitoneal masses and thoracic CT displayed multiple bilateral lung metastases. Histopathological evaluation of the biopsy specimen obtained from the maxillary sinus showed choriocarcinoma. Based on WHO criteria she was classified as high-risk metastatic choriocarcinoma and treated with combination chemotherapy. We believe that in young women with recurrent epistaxis, gross abnormal vaginal and rectal bleeding and atypical maxillary sinus tumor with multiple lung metastases, choriocarcinoma should be included in the differential diagnosis and previous history of pregnancy or abortion should be obtained.

The role of chemotherapy in malignant mixed mullerian tumors of the female genital tract

Thirteen patients with malignant mixed mullerian tumor of the female genital tract, treated and followed in our clinic from 1989 to 1999 were retrospectively evaluated. Seven patients (53.8%) with advanced disease or postoperative residual tumor were treated with adjuvant chemotherapy. The median age at diagnosis was 64 years (range: 26-79). All patients underwent primary surgical cytoreduction. Tumors were localized to the endometrium in five (62.5%), to the ovaries in two (25%) and to the fallopian tube in one (12.5%) patient. One patient with endometrial carcinosarcoma had a simultaneous second primary ovarian epithelial carcinoma. Two patients (25%) had a heterologous sarcomatous component. Myometrial involvement included less than half the thickness in one patient, while there was no myometrial invasion encountered in two patients. Five patients (38.5%) had more than 50% of the myometrium invaded. Two patients received additional radiotherapy. Six patients received cisplatinum-based chemotherapy (4 had doxorubicin including combinations), while one patient was treated with a doxorubicin+ifosphamide combination. Five patients (71.4%) had a complete response (CR) to chemotherapy. Response duration in patients with a CR was +13, +67, +10, +14 and +2 months, respectively. After a median follow-up period of 20 months (3-115 months), six patients have died, five are being followed-up with no evidence of disease, one is alive with metastatic disease and one patient is under treatment. Malignant mixed mullerian tumor of the female genital tract is highly responsive to multimodality treatment strategies. Further prospective studies are required to identify distinct prognostic groups that may benefit from various treatment modalities.

Autophagy and nuclear changes in FM3A breast tumor cells after epirubicin, medroxyprogesterone and tamoxifen treatment in vitro

OBJECTIVE

Autophagy is a form of physiological programmed cell death which is observable after hormonal withdrawal. In this study, the FM3A murine breast tumor cell line was treated with epirubicin alone and with medroxyprogesterone acetate (MPA) or tamoxifen, to determine if structural and kinetic signs of autophagy may also occur in an enhanced manner during epirubicin sensitization via hormonal agents.

METHODS

One-week soft agar colony growth, 96-hour values of plating and pulse thymidine labeling and electron microscopical examinations were performed following treatment with MPA and tamoxifen alone or with epirubicin.

RESULTS

Tamoxifen induced signs of autophagy, which was enhanced when it was combined with MPA. Epirubicin also induced autophagy of secretory granules, which coalesced to form an intracytoplasmic lumen. Combining MPA with epirubicin enhanced the formation of apoptotic blebs and chromatin fragmentation. When epirubicin was combined with tamoxifen, peculiar nuclear structures were formed.

CONCLUSIONS

Hormonal agents may modulate anthracycline activity towards specific patterns in eliciting cell death, via autophagy and/or as yet unknown nucleolus-specific interactions.

Acetaminophen modulations of chemotherapy efficacy in MDAH 2774 human endometrioid ovarian cancer cells in vitro

Epidemiological data have correlated consumption of nonsteroidal antinflammatory drugs with lowered risk for many types of cancer, and some recent studies indicate a reverse correlation with acetaminophen consumption and ovarian malignancy. In this study we examined effects of acetaminophen on plating, S-phase and colony growth of MDAH 2774 human endometrioid ovarian carcinoma, as well as sensitivity of this cell line to carboplatin in all three tests, and paclitaxel to clonogenic assay. Acetaminophen significantly enhanced S-phase in first 72 hours and enhanced cell population in 96 hours of plating monitorization, but decreased one week colony growth by approximately 80%, which was in the range of cytotoxic drugs. Interestingly with low dose carboplatin in first 72 hours acetaminophen enhanced cell proliferation more profoundly, but only thereafter decreased cell growth synergistically with carboplatin. It did not effect paclitaxel colony growth inhibiting acitivity. MDAH-2774 cell line lack p-53 and MSH-2, which are both 'gatekeeper' apoptosis inducing genes against genome damaging insult. Thus, presence of lower doses of oxidizing drugs may help the induction of proliferative signals, but only their sustained presence may overcome such signals and ultimately bring to cell demise.

Vascularization pattern of C6 glioma is modified with medroxyprogesterone acetate and ibuprofen in Wistar rat brain

Beneficial effects of medroxyprogesterone acetate (MPA) in cancer therapy is partly mediated via its antiangiogenic activity. The same is true for the antitumoral action of non-steroidal antiinflammatory drugs. We have studied two liposoluble drugs, MPA and the analgesic ibuprofen, on glioma vascularization in vivo. In this study we have shown that, until the sacrifice at 27. day after tumor inoculation in the right hemisphere, MPA had a slight though insignificant activity to reduce the fatality of C6 glioma, growing in right cerebral hemisphere of male Wistar rats. But ibuprofen both alone or with MPA had no effect on survival with gavage application of a 30 mg/kg/day dosing regime. On histological analysis, intra- and peritumoral vessels were counted. Progesterone seemed to lower intratumoral, but to increase peritumoral vessels, especially glomeruloids, around the tumor mass. Coadministration of ibuprofen acted to suppress the peritumoral vessel increase, and to enhance lymphomonocytic infiltration around tumor vessels.

5-fluorouracil-induced balanitis in a patient with oesophageal carcinoma

We have reported the case history of a patient with balanitis, who was treated with 5-FU. Although 5-FU has a wide toxicity profile, balanitis has not been reported in association with this therapy.

Prognostic factors in pancreatic carcinoma: serum LDH levels predict survival in metastatic disease

In this study, our aim was to investigate the impact of various prognostic factors on survival in patients with pancreatic carcinoma. The group consisted of 127 cases with adenocarcinoma histologically. The patients had a median age of 58 years, and 81 (64%) were male. The median survival time of the whole group was 7 months, and the 4-year survival rate was 18%. The median survival duration of the patients without metastases was 8 months, and the survival rate at 1 year was 37.5% and 7.2% at 5 years. It was associated with improved survival compared with the cases with metastatic disease (p < 0.0001). In univariate analysis, decreased performance status (p = 0.0009) and unresectability of tumor (p < 0.0001) were associated with poor outcome. However, only surgery was found to be a statistically significant parameter in multivariate analysis (p = 0.002). The median survival duration of patients with metastases was 5 months, and the 1-year survival rate was 10%. Age younger than 60 years (p = 0.04), decreased serum hemoglobin levels (p = 0.04), and elevated lactic dehydrogenase (LDH) levels (p = 0.0001) were associated with a significantly shorter survival rate. In the Cox model, a high serum LDH level was the only independent unfavorable prognostic factor (p = 0.001). In conclusion, surgical intervention in the group without metastases and serum LDH levels in the group with metastases were the most important prognostic factors influencing survival. Pretreatment serum LDH determinations may provide a useful means of stratifying patient populations when comparing treatment programs for advanced pancreatic cancer.

Thymidine labeling index in epithelial ovarian cancer

OBJECTIVE

The aim of this study is to determine the thymidine labeling index and its prognostic role in patients with ovarian cancer.

METHODS

Tumor cell proliferation in 32 patients with primary ovarian cancer admitted to Istanbul Medical Faculty, Department of Obstetrics and Gynecology, between 1993 and 1997 was investigated using the [3H]thymidine labeling index (TLI). TLI results were compared with other clinical and histopathologic prognostic parameters.

RESULTS

The mean and median TLI values of the patients were 9.3+/-6.2% and 9.20% (range: 0.4-23.0%), respectively. Sixteen patients showed high proliferation rates (mean TLI: 14.3%). These patients had an overall survival rate of 46.7% at 3 years. The mean TLI level and overall survival at 3 years in the low proliferation rate group were 4.4 and 68.8%, respectively. Patients with a high TLI had a significantly shorter survival compared to those with a low TLI (P<0.01). There was tendency towards a higher TLI with advanced stage (P>0.05). However, there was no statistically significant correlation between TLI and other prognostic parameters.

CONCLUSION

TLI may have a predictive value in determining the outcome of patients with ovarian cancer. Further larger scale studies are needed before definite conclusions can be made about its role as a prognostic factor in this disease.

The efficacy of combination chemotherapy including intraperitoneal cisplatinum and mitoxantrone with intravenous ifosfamide in patients with FIGO stage I C ovarian carcinoma

OBJECTIVE

Patients with stage I ovarian cancer show a high incidence of recurrent disease ranging from 30% to 50%, which may be associated with a shortened survival. Therefore, a subset of early-stage patients with poor prognostic factors who are most likely to present with recurrent disease in the next few years may benefit from adjuvant treatment.

PATIENTS AND METHOD

In this pilot study, we evaluated the efficacy of combination chemotherapy including intraperitoneal mitoxantrone (12 mg/ml) and cisplatinum (75 mg/ml) on day 1, in addition to intravenous ifosfamide (4000 mg/m2) given on day 15 with mesna protection. Thirteen patients with a median age of 44 years were included in the study.

RESULTS

Following a median of 5 cycles of chemotherapy, 12 patients had a complete response (92.3%), while one patient had progressive disease. At the latest follow-up, ten patients were alive with no evidence of disease, two patients had died and one patient was lost to follow-up. Overall and progression-free survival rates at eight years were 82.5+/-11.3% and 83.9+/-10.5%, respectively. Excluding grade 3 and 4 abdominal pain in three (23.1%) patients, there were no serious complications associated with this combination. Dose delay not longer than one week was observed in 3 cycles (5.6%). Port-related complications observed in three patients were colonic perforation, hematoma and leakage.

CONCLUSION

This combination has moderate efficacy and tolerable toxicity. However, further studies are required to make definite conclusions regarding the efficacy of this combination in the adjuvant setting in patients with high-risk early stage ovarian carcinoma.

Stevens-Johnson syndrome in a patient receiving anticonvulsant therapy during cranial irradiation

A 28-year-old female patient with a recent history of breast carcinoma was referred to our clinic with generalized necrotic skin eruptions and severe mucosal erosions, which developed right after the completion of cranial radiotherapy for brain metastases. She had been receiving prophylactic diphenylhydantoin treatment 100 mg three times daily during radiation therapy. The extensive involvement of the oral mucosa with conjunctivitis and synechiae of the eyelids, facial swelling, and extension of the rash over the trunk and shoulders with bullous detachment of less than 10% of the total body surface strongly suggested Stevens-Johnson syndrome caused by phenytoin treatment in our patient. There has been conflicting evidence on the role of radiotherapy in the increased risk of severe drug reactions. Although various authors have emphasized the augmented rate of severe mucocutaneous reactions caused by anticonvulsants given during radiotherapy and suggested discontinuing the prophylactic use of such drugs in patients with no history of seizures, others have argued in favor of prophylactic anticonvulsants. Given the high risk of seizures, reaching 20% in patients with brain tumors, and the low incidence of drug reactions, the suggestion of refraining from prophylactic anticonvulsants in the setting of primary or metastatic brain tumors is controversial.

Serum lactate dehydrogenase levels at presentation predict outcome of patients with limited-stage small-cell lung cancer

Serum lactate dehydrogenase (LDH) is a biochemical parameter that is elevated in the majority of extensive-stage small-cell lung cancer (SCLC). In this study, distribution and prognostic importance of serum LDH in limited-disease SCLC were investigated. Serum concentrations of LDH were measured in 184 patients at initial examination. These results were compared with prospectively recorded clinicopathologic characteristics and patient outcome data. Significant positive association was found between LDH levels and weight loss, performance status, response to chemotherapy, and albumin but not between age, gender, and hemoglobin values. Patients with high concentrations of LDH had a significantly worse prognosis than did patients with normal levels. The probability of overall survival at 1 year was 60.2% in patients with normal serum LDH levels and 33.1% in patients with higher values (p = 0.0017). Also, the prognostic value of LDH on overall survival was shown in multivariate analysis (p = 0.05). At the time of diagnosis, serum levels of LDH appear to have a significant relation to outcome in patients with limited-stage SCLC.

Biological considerations in locally advanced breast cancer treated with anthracycline-based neoadjuvant chemotherapy: thymidine labelling index is an independent indicator of clinical outcome

The present retrospective study aims to determine the clinical value of thymidine labelling index (TLI) together with other established clinical and biological factors in 116 locally advanced breast cancer (LABC) patients treated with anthracycline-based neoadjuvant chemotherapy, surgery, adjuvant chemotherapy and radiotherapy. TLI was determined in 71 LABC patients with a median of 2.62% (0-23.64%) and a mean of 4.71% +/- 5.54. As a result of neoadjuvant chemotherapy, 85 patients (73%) responded to chemotherapy (CT), whereas 31 patients were unresponsive (27%). No relationship has been found between the pretreatment biological variables including TLI, estrogen receptor (ER), progesteron receptor (PgR) status and clinical parameters such as the chemotherapy response rates and axillary lymph node involvement following chemotherapy. Median follow-up was 35 months (18-97 months) and the 3-year overall survival (OS) and disease free survival (DFS) rates were 71.6% and 52.2%, respectively. In univariate analysis, patients with inflammatory breast cancer, high TLI-index (> or = 2.62%), lymph node (LN) positivity or > 3 positive lymph nodes following neoadjuvant chemotherapy and without any response to neoadjuvant chemotherapy were found to have worse DFS and OS-rates and high local and systemic recurrence rates. In multivariate analysis, TLI was estimated as the most powerful independent factor affecting the OS in LABC patients among the other established clinical and biological parameters (p = 0.02). These results suggest that TLI is an important independent indicator of clinical outcome in patients with LABC and these patients with high TLI levels require more effective treatment modalities.

Correlations of serum CA125 level and computerized tomography (CT) imaging with laparotomic findings following intraperitoneal chemotherapy in patients with ovarian cancer

The aim of this study was to evaluate the role of serum CA125 levels and computerized tomography (CT) scans in predicting pathologic response of intraperitoneal chemotherapy in patients with ovarian cancer. We prospectively analyzed serum CA125 levels and abdominopelvic CT scans obtained after the completion of intraperitoneal chemotherapy in 52 patients with ovarian cancer and compared the results with subsequent laparotomic findings, which served as the gold standard for statistical analysis. Laparatomy revealed either microscopic or macroscopic residual disease in 20 patients, while 32 patients were completely tumor-free. CA125 levels correlated significantly with laparotomic findings (p=0.003, u=1405). Median CA125 values in patients with residual tumors and in tumor-free patients following intraperitoneal chemotherapy were 14.6 (1-775) and 7.2 (1-37) U/ml, respectively. Although CT-imaging and CA 125 levels had a high specificity (100% and 96.9%, respectively), they showed a low sensitivity rate (50% and 40%, respectively). Similarly, despite high positive predictive values (100% and 88.9%, respectively), the negative predictive values were 76.2% and 72.1%, respectively.

CONCLUSION

Although highly specific, CT scans and CA125 levels do not accurately indicate the presence of disease. Due to a high false-negative rate, a normal CT scan or a normal CA125 value is not sufficient to replace a laparotomy.

Measurement of serum CA 19-9 may be more valuable than CEA in prediction of recurrence in patients with gastric cancer

In 35 patients with recurrent gastric cancer who had undergone curative gastrectomy, serum carcinoembryonic antigen (CEA) and CA 19-9 (carbohydrate antigen) tumor marker levels were investigated. At least one tumor marker was elevated in 24 (68.6%) patients. The levels of serum CA 19-9 and CEA markers were increased in 20 (57.1%) and 12 (34.3%) patients, respectively. This difference was not statistically significant. However, it may be important in terms of clinical practice.

Crossover clinical study comparing the pharmacokinetics of etoposide (75 mg) administered as 25-mg capsules three times a day versus once a day

Some investigators have postulated that a constant low blood level might be the ideal mode of treatment, while others have seen no reason to divide up the daily dose. To our knowledge, this study is the first to include crossover of subjects to eradicate individual differences. Our aim was to compare the pharmacokinetic effects of administering etoposide three times a day vs. once a day as 25 mg capsules. Two groups of four patients each received 75 mg/day oral etoposide for 2 days either as 75 mg once daily, or as 25 mg three times daily for 2 days. On days 8 and 9, the treatments were switched between groups. On the one-dose schedule, Cpeek (peak plasma concentration) was greater than 2 micrograms/ml in five patients and greater than 3 micrograms/ml in three patients, while in none of the patients on the three-dose schedule did the peak exceed 2 micrograms/ml. No significant difference was found in terms of Cmean (calculated by dividing the area under the curve by the observed time) between the two treatments. Variability of blood concentrations of etoposide over a 24 h period was high on the one-dose schedule (median 95%, range 54-148%) but it was lower on the three-dose schedule (median 39%, range 28%-55%). No significant differences were found between the two different dosing schedules in terms of the median duration of etoposide blood levels above 0.5 microgram/ml and above 1.0 microgram/ml. These results suggest that detailed clinical toxicity and efficacy data are needed to clarify the possible benefits of the fractionated administration of oral etoposide.

Angiogenesis and p53 protein expression in breast cancer: prognostic roles and interrelationships

The authors have analyzed, on the one hand, the prognostic impact of microvessel density (MVD) and p53 protein expression in patients with breast cancer, and on the other hand, the correlation between the microvascular pattern and the p53 protein expression. Tumors from 120 patients whose paraffin-embedded tissue blocks were available were analyzed using the immunohistochemical method. MVD and p53 protein expression were correlated with histologic grade and tumor size, respectively. The patients with highly vascularized tumor (high MVD) had decreased overall survival (p = 0.04), whereas overexpressed p53 patients did not. In multivariate analysis, axillary lymph node status (p = 0.007), tumor size (p = 0.01), and MVD (p = 0.02) showed important prognostic influence on overall survival. When the simultaneous influence of MVD and p53 protein expression on survival were analyzed, no interrelationship was detected. The results demonstrate the prognostic impact of MVD on overall survival in breast cancer and no association between MVD and p53 protein expression.

Utility of the serum tumor markers: CYFRA 21.1, carcinoembryonic antigen (CEA), and squamous cell carcinoma antigen (SCC) in squamous cell lung cancer

The aim of this study is to assess the clinical usefulness of serum assays of carcinoembryonic antigen (CEA), squamous cell carcinoma antigen (SCC), and CYFRA 21.1 in the diagnosis of squamous cell lung cancer. Sixty patients with squamous cell, and twenty-four patients with nonsquamous cell histology of nonsmall cell lung cancer were enrolled in this study. Serum CEA, SCC, and CYFRA 21.1 levels were obtained by commercially available kits. Upper cutoff levels were 10 ng/ml, 3.5 ng/ml, and 3.5 ng/ml, respectively. In squamous cell lung cancer, percentages and 95% confidence interval (CI) of the patients with elevated levels were as follows: for CEA 23.3% (13-36), for SCC 20.0% (10-32), and for CYFRA 21.1 85.0% (73-93). The positivity rate of CYFRA 21.1 was more significant than CEA and SCC in both squamous and nonsquamous cell lung cancer. None of the markers were significant in differentiating squamous/nonsquamous histology. Only tumor marker CEA was significantly elevated in metastatic squamous cell lung cancer (p=0.004). A novel tumor marker CYFRA 21.1 can be used as a reliable tumor marker in diagnosing squamous cell lung cancer. In addition, CEA has an important role in determining metastatic disease.

Multiple primary neoplasms at a single institution: differences between synchronous and metachronous neoplasms

During the 10-year period (1987-1996) of our study, 26,255 patients with cancer were admitted to our clinic and, of these, 271 (1%) patients had multiple primary malignant tumors. Ninety-two (34%) patients had synchronous tumors (synchronous group), and 179 (66%) patients had metachronous tumors (metachronous group). The mean age at first diagnosis was higher in the former group. The ratio of men to women was 1.36 in the synchronous group and 0.74 in the metachronous group (p = 0.018). Smokers and drinkers were more common in the synchronous group. Breast cancer and lung cancer were most prevalent, and associations between head/neck and lung cancer and between breast and breast cancer were the most frequent associations in both the synchronous and the metachronous group. The frequency of aerodigestive tumors was higher and that of mesenchymal tumors was lower in the synchronous group than in the metachronous group. Localization in the medial region and in the head/neck was more frequent in the synchronous group than in the case of metachronous secondary tumors.

Celsite port and catheter as an intraperitoneal access device in the treatment of ovarian cancer

BACKGROUND AND OBJECTIVES

In ovarian cancer, development of safe and effective methods for providing long-term access to the peritoneal cavity has become increasingly important.

METHODS

A modified Port-A-Cath (Celsite-port and catheters, B. Braun, Chasseneuil, France) was used in 56 patients with presumed epithelial ovarian cancer at the conclusion of primary or second-look laparotomy. In 37 patients, ports were located on the right costal margin in the midclavicular region and in 19 in the xiphoid region.

RESULTS

In 56 catheters, 8 (13.8%) complications of severe or moderate degree during the treatment were registered. In-flow obstruction of device occurred in 6 patients, and there was 1 viscous perforation and 1 catheter related infectious peritonitis. Grade III-IV pain and in-flow obstruction were developed in the patients with ports implanted on the right costal margin but not with ports implanted in the xiphoid region.

CONCLUSION

The complication rate of intraperitoneal access devices is comparatively low.

Factors influencing the distribution of metastases and survival in extensive disease small cell lung cancer

This study was conducted to investigate the distribution of metastatic lesions and their influence on survival, as well as other prognostic factors previously shown to have an impact on the outcome of patients with extensive small cell lung cancer (SCLC). Of the 207 patients were included and retrospectively analyzed; 124 patients had extended disease at initial presentation and the remaining 83 developed metastatic disease during follow-up. Patients who relapsed presented most frequently with distant metastases. The brain was the most frequent organ targeted for metastatic disease following the completion of chemotherapy (p<0.05). Serum LDH levels correlated significantly with the presence of liver metastasis (p<0.001). The site of involvement did not seem to have an impact on survival. Nevertheless, patients with multiple metastatic sites had a significantly poor survival rate (p = 0.001). Weight loss, performance status, gender, clinical stage, serum LDH and albumin levels were all shown to correlate with survival (p<0.05). Response to chemotherapy was determined to be the most important prognostic factor.

The roles of chemotherapy and surgery in gastric carcinoma and the influence of prognostic factors on survival

In this study, we present the results of surgery and chemotherapy and the impact of various prognostic factors on survival in patients with gastric carcinoma with a follow-up of 6 years. All of the 328 cases were adenocarcinoma histologically and had a median age of 55 years. Median survival was 11 months, and the 5-year survival rate was 18%. Nonmetastatic cases were associated with improved survival as compared with the cases with metastatic disease (p<0.001). Patients with gastrectomy had improved survival (p<0.001). Subtotal gastrectomized patients had better survival rates in comparison to the total gastrectomized patients (p = 0.03). Addition of splenectomy to total gastrectomy and adjuvant chemotherapy did not influence survival rates (p>0.05). In metastatic patients, we determined beneficial effects of gastrectomy and chemotherapy on survival. The benefit was most predominant in chemoresponsive patients (p<0.001). Higher serum CA 19.9 levels in patients without metastases, higher serum lactate dehydrogenase and carcinoembryonic antigen levels in patients with metastases, and lower serum albumin levels in both stages were determined as significant predictors of poor survival. On multivariate analysis, only higher serum CA 19.9 level was the independent unfavorable prognostic factor of survival time in nonmetastatic patients (p = 0.008). In metastatic disease, older age (p = 0.03) and male gender (p = 0.05) were associated with poorer survival. In conclusion, gastric cancer is a great health problem, especially in developing countries, and we need more optimal approaches and treatment modalities for gastric cancer.

Response evaluation of bone metastases in breast cancer: value of magnetic resonance imaging

The clinical utility of magnetic resonance imaging (MRI) in judging therapeutic response of bone metastases was evaluated in 18 patients with advanced breast cancer. Treatment efficacy was assessed by MRI and conventional methods such as plain radiograph, bone scan, pain and analgesic scale, and serum CA15-3. The response by MRI was evaluated mainly on T1-weighted sequences by measuring the volume of the bone lesion and soft tissue component. The patient was assumed to be a conventional responder if a complete or partial response was observed in any of the conventional methods described above. Response was most concordant between plain radiographs and MRI findings (91%, 10/11, 95% confidence interval [CI]: 58.7-99.8). The rate of concordance was 61% (11/18, 95% CI 35.8-82.7) for all conventional methods and MRI. MRI revealed response in four patients in whom progressive disease was observed by bone scan and the marker response was not measurable. This pilot study suggests that posttherapy evaluation with MRI may provide useful clinical information in breast cancer patients with bone metastases and may be a valuable adjunct to conventional methods with conflicting results.

Catheter complications associated with intraperitoneal chemotherapy

Catheter complications associated with intraperitoneal chemotherapy were evaluated in 171 patients (pts) with primary intra-abdominal malignancies. In 96 pts and 488 courses, single-use catheters (SUC) (3/G 14 Braun) were used between years 1990-1993. In 75 pts and 283 courses a semi-permanent subcutaneous implantable port and catheter system (SIPC) (T 2035/460 mm-F 14-76 Braun) was used between years 1993-1996. Cisplatin (60-75 mg/sqm), 5-fluorouracil (600 mg/sqm), calcium folinate (150 mg), etoposide (180 mg/sqm), mitoxantrone (12-15 mg/sqm) were given in various combinations and periods to patients with ovarian carcinoma (106 pts), gastrointestinal carcinoma (43 pts), hepatocellular carcinoma (17 pts) and mesothelioma (5 pts). The incidence of patients with complications was significantly higher in SUC (45%) than SIPC (23%) (p=0.001). Colon puncture (8.8%, p<0.0001) and subcutaneous leakage (3.7%, p<0.01) rate of the courses were significantly higher in SUC. Pain related to catheter complications (6%, p<0,0002), local infection (1.4%, p=0.02) and obstruction (1.4%, p=0.02) were significantly higher in SIPC. The most important local complications were intra-abdominal fibrosis and adhesions that were surgically documented in 90% of the ovarian cancer patients, and were more severe in patients with the SIPC system. The complication rate and the complication type of these two catheters were found to be significantly different in this retrospective analysis; in order to determine the real complication rate, safety, efficacy and overall acceptability of the catheters, a randomised trial is needed.

Paraneoplastic limbic encephalitis with immature ovarian teratoma--a case report

Paraneoplastic limbic encephalitis (PLE) is a remote, nonmetastatic complication of carcinoma. Neuropsychiatric symptoms usually predate the diagnosis of cancer by 3 months to 6 years and very rarely the symptoms develop after the diagnosis of malignancy. We report the first case of limbic encephalitis associated with an immature ovarian teratoma. Within the month following the diagnosis of the tumor with pathologic stage Ia, somewhat acutely she developed neuropsychiatric symptoms that was exclusively a limbic disorder with impairments in almost every realm of limbic function. This case may show us that it is important to recognize the neuropsychiatric symptoms of PLE as the first manifestation of a very small malignant ovarian tumor and to aggressively try to identify the underlying cancer.