Mitomycin C and Vinblastine in Anthracycline-resistant Metastatic Breast Cancer: A Phase Ii Study

The purpose of this phase II study was to evaluate the clinical efficacy of mitomycin C and vinblastine in patients with anthracycline-resistant metastatic breast cancer. This single-center, non-randomized trial enrolled 39 patients. Eligible patients must have received at least three chemotherapy regimens with epirubicin or CAF and had treatment failure while on chemotherapy or within 6 months of completing therapy. Treatment consisted of mitomycin C at a starting dose of 8 mg/m2 on day 1 and vinblastine (8 mg/m2, days 1 and 28). The regimen was repeated every 6 weeks with a 20% dose escalation of both drugs after the first cycle in the absence of grade III hematologic or other toxicity. On an intent-to-treat basis, 38 patients were eligible for assessment; 9 (23.7%, 95% confidence interval 1.92-2.45%) achieved a partial response and 13 (34.2%) had stable disease. The median time to disease progression was 6.21 ±4.26 months (range, 1-15; 95% confidence interval, 4.81-7.61), and the median survival was 10.76±7.6 (range, 1-29; 95% confidence interval 8.0-13.1%). Responsive patients had a significantly better survival than those with stable and progressive disease. Treatment was well tolerated. Anemia and neutropenia (grade I-III) developed in 28.9% and 26.3% of the patients, respectively. One patient with grade III granulocytopenia developed fever and infection that required hospitalization. Moderate neurotoxicity, myalgia, constipation, diarrhea and alopecia were observed. No toxic death occurred. Mitomycin C plus vinblastine is an effective and well-tolerated regimen for anthracycline resistant cancer.

Sentinel node biopsy in male breast carcinoma: is the "female" approach justified?

PURPOSE

Mastectomy with axillary lymph node dissection (ALND) represents the gold standard in the treatment of male breast carcinoma. Recently, data have emerged supporting that sentinel lymph node biopsy (SNB) may be feasible in selected patients. The aim of this study was to analyze the safety and prognostic reliability of SNB in male patients with breast carcinoma and clinically negative axilla.

METHODS

During a 10-year period (2000-2010), 11 men with mean age 66.1 years (range 34-84) diagnosed with breast carcinoma were retrospectively included to our study. All patients underwent SNB. Regardless of the SNB results, completion axillary clearance was conducted in all cases.

RESULTS

SNB detection rate was 100%, while the mean number of sentinel nodes removed was 1.5 +/- 0.7 (range 1-2). Frozen section analysis revealed a negative sentinel node in four out of 11 patients (36.4%). Independently of these results, all patients underwent completion ALND. The overall false-negative rate, defined as the percentage of all node-positive tumors in which the SNB was negative, was 0%.

CONCLUSION

The current study indicates that SNB may be feasible in selected male individuals with breast carcinoma. The technique may reduce the morbidity related to dissection of the axilla; prospective multicenter trials are needed in order to define the exact criteria for wider application of this technique.

Necrotizing fasciitis of the head and neck: report of 5 cases and review of the literature

BACKGROUND

Necrotizing fasciitis (NF) is a severe, rapidly spreading soft tissue infection of polymicrobial origin. This condition most frequently affects thorax, abdominal wall, extremities, perineum and groin, but according to recent literature the head and neck area is also involved with increasing frequency.

PATIENTS AND METHODS

Five cases of head and neck NF were detected among patients who were admitted at the Department of Otorhinolaryngology-Head and Neck Surgery of the University Hospital of Patras, Patras, Greece, over a 5-years period. Various parameters including patients' health status, co-morbidity, etiology, microbiology, affected area, antibiotic therapy, hospital stay, surgical treatment and complications were considered.

CONCLUSIONS

The management of NF should comprise of hemodynamic and respiratory evaluation and monitoring, broad-spectrum i.v. antimicrobial therapy, surgical debridement and nutritional support. Close postoperative management of NF patients remains of paramount importance.

Is sentinel node biopsy reliable in large breast tumors?

PURPOSE

The value of sentinel lymph node biopsy (SNB) in patients with larger breast tumors (diameter > 3 cm) has been questioned due to high false-negative rates reported from initial studies. The aim of this study was to analyze the safety and prognostic reliability of SNB in this group of patients.

METHODS

During a 6-year period (2001-2007), 84 women with mean age 51.7 +/- 11.6 years diagnosed with a breast tumor larger than 3 cm in diameter on pathological analysis were retrospectively identified from the database of our institution. Sentinel node identification was performed after injection of blue dye subcutaneously at the subareolar area. The sentinel node specimen was sent for frozen section analysis. Regardless of the SNB results, all patients underwent completion axillary clearance.

RESULTS

Breast surgery consisted of mastectomy in 62 patients (73.8%) and partial mastectomy in 22 patients (26.2%). There were 69 invasive ductal cancers (82.1%), 14 lobular cancers (16.6%) and one case of anaplastic carcinoma (1.3%). Nine tumors (10.7%) were identified to be multifocal after the histopathological report. The mean number of sentinel nodes removed was 1.5 +/- 0.7 (range 1-4) while SNB detection was not feasible in three patients (3.6%). Of 56 positive SNBs, seven (12.5%) were not identified by routine hematoxylin and eosin staining during frozen section analysis but were detected by subsequent immunohistochemistry on the final histopathological report. All patients with multifocal tumors presented nodal metastases on pathological analysis (100%), while the rate of nodal metastatic disease in patients with unifocal tumors was 16% (12 patients), although no statistical significance was documented. The overall false-negative rate, defined as the percentage of all node-positive tumors in which the SNB was negative, was 14.3%. The false-negative rate was significantly higher for the group of patients with multifocal tumors (55.5%) compared to the group with unifocal tumors (9.3%) (p < 0.001).

CONCLUSIONS

The present study indicates that sentinel node biopsy is feasible in patients with larger breast tumors (max. diameter > 3 cm), with comparable false-negative and sentinel detection rates (14.3% and 96.4%, respectively). Larger tumor size seems to be associated with increased incidence of nodal metastases while multifocality appears to be related to increased false-negative rates; hence completion axillary clearance should be initially considered for these cases.

The Effect of Exemestane on the Lipidemic Profile of Postmenopausal Early Breast Cancer Patients: Preliminary Results of the TEAM Greek Sub-study

INTRODUCTION

Long-term endocrine therapy for breast cancer may have clinical implications as drugs that potentially alter the lipid profile may increase the risk of developing cardiovascular disease. In this study, a companion sub-protocol to the TEAM (Tamoxifen and Exemestane Adjuvant Multicenter) International trial, we compared the effect of the steroidal aromatase inactivator exemestane on the lipid profile of postmenopausal women with early breast cancer in the adjuvant setting to that of tamoxifen.

PATIENTS AND METHODS

In this open-label, randomized, parallel group study, 176 postmenopausal patients with estrogen and/or progesterone receptor positive early breast cancer were randomized to either adjuvant exemestane (25 mg/day; n = 90) or tamoxifen (20 mg/day; n = 86). Assessments of total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL) and serum triglycerides (TRG) were performed at baseline and every 3 months for the first 12 months.

RESULTS

Serum triglyceride levels were consistently increased above baseline throughout the study in the tamoxifen arm, while there was a trend towards reduction in the exemestane arm. There was also an overall trend for tamoxifen to decrease the levels of LDL throughout the study period. Exemestane did not demonstrate any other significant change in HDL levels; however, there was a consistent trend for a reduction in total cholesterol in both treatment arms. The atherogenic risk determined by the TC:HDL ratio remained stable in both arms throughout the treatment period.

CONCLUSIONS

Exemestane appears to have a neutral effect on total cholesterol and HDL levels. Unlike tamoxifen's positive effect on LDL levels, exemestane does not significantly alter LDL levels. Tamoxifen on the other hand increases triglyceride levels, while exemestane results in a beneficial reduction in TRG levels. These data offer additional information with regard to the safety and tolerability of exemestane in postmenopausal breast cancer patients and support further investigation of its potential usefulness in the adjuvant setting.

Expression of the cell cycle regulatory proteins p34cdc2, p21waf1, and p53 in node negative invasive ductal breast carcinoma

AIMS

To look for correlations between expression of cell cycle regulatory proteins p34(cdc2), p21(WAF1), and p53 in node negative invasive ductal breast carcinoma, or between these proteins and clinicopathological parameters, and to assess their prognostic value.

METHODS

Immunohistochemistry using formalin fixed, paraffin wax embedded sections from 94 breast carcinomas. Adjacent benign epithelial breast tissue was available in 74 cases. Median follow up was 72 months.

RESULTS

Nuclear and cytoplasmic p34(cdc2) expression was seen in 80 and 62 tumours, respectively; nuclear expression was seen in adjacent benign epithelium in 12 cases. p21(WAF1) and p53 were positive in 48 and 21 tumours, respectively. High expression of p34(cdc2) in neoplastic nuclei was associated with higher histological grade and p53 expression, but not with tumour size, steroid receptor status, patient age, menopausal status, recurrence, metastasis, disease free survival (DFS), or overall survival (OS). p34(cdc2) in tumour cytoplasm was associated with p34(cdc2) nuclear positivity, high tumour grade, and DFS in univariate but not multivariate analysis. In contrast, p34(cdc2) expression in benign tissue independently predicted DFS and OS in univariate and multivariate analysis. Expression of p53 was associated with high tumour grade and negative steroid receptors, but not with recurrence, metastasis, DFS, or OS. p21(WAF1) expression was not associated with the examined parameters.

CONCLUSIONS

p34(cdc2), p21(WAF1), and p53 expression does not predict outcome in node negative breast carcinoma, although p34(cdc2) expression in benign tissue is related to prognosis. The association between p34(cdc2) and p53 implicates p53 in G2-M cell cycle checkpoint control, possibly via mediators unrelated to p21(WAF1).

Adjuvant cytotoxic and endocrine therapy in pre- and postmenopausal patients with breast cancer and one to nine infiltrated nodes: five-year results of the Hellenic Cooperative Oncology Group randomized HE 10/92 study

SUMMARY

The present randomized phase III trial was designed to detect a 15% benefit in relapse-free survival (RFS) or overall survival (OS) from the incorporation of adjuvant tamoxifen to the combination of CNF [cyclophosphamide, 500 mg/m2; mitoxantrone (Novantrone), 10 mg/m2; fluorouracil, 500 mg/m2 chemotherapy and ovarian ablation in premenopausal patients with node-positive breast cancer and conversely from the incorporation of CNF chemotherapy to adjuvant tamoxifen in node-positive postmenopausal patients. From April 1992 until March 1998, 456 patients with operable breast cancer and one to nine infiltrated axillary nodes entered the study. Premenopausal patients were treated with six cycles of CNF chemotherapy followed by ovarian ablation with monthly injections of triptoreline 3.75 mg for 1 year (Group A, 84 patients) or the same treatment followed by 5 years of tamoxifen (Group B, 92 patients). Postmenopausal patients received 5 years of tamoxifen (Group C, 145 patients) or 6 cycles of CNF followed by 5 years of tamoxifen (Group D, 135 patients). Adjuvant radiation was administered to all patients with partial mastectomy. After a median follow-up period of 5 years, 125 patients (27%) relapsed and 79 (17%) died. The 5-year actuarial RFS for premenopausal patients was 65% in Group A and 68% in Group B (p = 0.86) and for postmenopausal patients 70% in Group C and 67% in Group D (p = 0.36). Also, the respective OS rates were 77% and 80% (p = 0.68) for premenopausal and 84% and 78% (p = 0.10) for postmenopausal patients. Severe toxicities were infrequently seen, with the exception of leukopenia (18%), among the 311 patients treated with CNF. In conclusion, the present study failed to demonstrate a 15% difference in RFS in favor of node-positive premenopausal patients treated with an additional 5 years of tamoxifen after CNF adjuvant chemotherapy and ovarian ablation. Similarly, six cycles of CNF preceding 5 years of tamoxifen did not translate to a 15% RFS benefit in node-positive postmenopausal patients.

The role of nasogastric tube after elective abdominal surgery

PURPOSE

Nasogastric tube (NGT) is routine employed after abdominal surgery still in our country and abroad too, but the patients' discomfort is severe and several serious complications were referred as related to its use. The aim of this study was to evaluate the pros and cons of routine use of NGT in elective uncomplicated abdominal surgery.

PATIENTS AND METHODS

In order to evaluate the routine use of NGT we performed a prospective randomized trial on 100 patients who had elective uncomplicated abdominal surgery: 50 subjects had the early removal of NGT and in 50 patients it was maintained until passage of flatus/feces.

RESULTS

The relevant differences between the two groups were the earlier passage of flatus and feces and the lower incidence of postoperative gastrectasy in the group where NGT was early removed. No statistical difference was recorded concerning the occurrence of postoperative nausea, vomiting, abdominal distension, complications and day of clinical release.

CONCLUSIONS

The routine application of NGT in elective abdominal surgery could be omitted if the surgeon and nursing team are willing to renounce a useful tool in providing informations about the resolution of postoperative intestinal atony to the patient's benefit: in fact a severe discomfort due to the NGT was recorded in the 70% of our series.

Prognostic significance of factors affecting disease free interval and overall survival for Stage II breast cancer in Greece. A multivariate cohort study

BACKGROUND

Univariate analysis evaluates the impact of a prognostic factor on survival rates, either disease free (DFI) or overall (OS). Since many of the factors are interrelated, it is difficult to predict the prognosis of an individual patient. Multivariate analysis is therefore required in order to allow factors act together thus ending in the best possible combined predicting result.

METHODS

A step-up procedure (Cox's Proportional Hazards Regression model) was used to include various prognostic parameters, relating to patients themselves, to the pathology of their tumours and to the treatment schedule followed. Two hundred and sixty-nine Stage II breast cancer Greek patients, treated from 1981 until 1991 and with a median 12-year of follow-up are studied.

RESULTS

Five factors were found to be significant for patients DFI. In order of relevant importance, these were the number of infiltrated nodes, tumour size, postoperative radiotherapy, adjuvant chemotherapy and patients age. Regarding patients OS, tumour size, number of positive nodes, patients' age at entry and ER/PR status were the most important ones.

CONCLUSION

Our long-term (12-year), single institution, single area results, suggest that, the prognostic factors for patients DFI and OS are the same with those of series from Europe and USA. Additionally, they remain unchanged after long-term follow-up, compared to a previously reported short-term national-wide study from this country.

Adjuvant tamoxifen versus tamoxifen plus CMF in the treatment of early breast cancer in Greece. Fifteen-year results of a randomised prospective trial and the potential risks of the antioestrogen

BACKGROUND

CMF and Tamoxifen are the most commonly administered drugs for the adjuvant treatment of early-stage breast cancer. We present the 15-year follow-up of our 250-patient series and evaluate the oestrogenic side-effect of Tamoxifen on the endometrium.

PATIENTS AND METHODS

250 women entered this prospective study from 1981-1986. They had all undergone modified radical mastectomyl and were randomly assigned to receive either Tamoxifen only for 4 years or combination of Tamoxifen with 6 cycles of standard CMF. Abdominal sonogram was used to determine endometrial thickness, with 6 mm as cut-off limit for endometrial biopsy.

RESULTS

After 15.6 years of follow-up DFS and OS rates were better for the CMF + Tamoxifen, group (52.8% vs 39.2%--p = 0.043 and 57.6% vs 40.8%--p = 0.006 respectively). Only patients with more than 4 infiltrated nodes did not significantly benefit from adjuvant CMF. Postmenopausal women suffered more proliferative endometria compared to premenopausal ones (40.3% vs 15.6%), while life-threatening lesions (cancer and atypias) were found in 3.3% of the postmenopausal patients only.

CONCLUSION

CMF + Tamoxifen combination offers better long-term results for early-stage breast cancer patients. Dose reduction must be avoided if maximum results are to be achieved. More than 4 positive nodes seem to require additional chemotherapeutic manipulation. Tamoxifen's oestrogenic side-effect on the endometrium is quite common, but life-threatening lesions are rare, thus proving the drug's safety.

Prognostic variables in greek patients with stage II breast cancer: a Hellenic Cooperative Oncology Group study

The independent effects of several patient, tumor and treatment-related prognostic factors on relapse-free survival (RFS) and overall survival (OS) were assessed by Cox multivariate regression analysis in 988 Greek patients with stage II breast cancer. At a median follow-up time of 83 (range 3.3-131+) months and after the evaluation of all patients together, the number of positive axillary nodes (p < 0.0001), tumor size (p = 0.0024) and tumor grade (p = 0.0008) were identified as significant prognostic factors for RFS. Also, the number of positive nodes (p < 0.0001), tumor size (p = 0.0002) and ER status (p = 0.0001) were found to be significant for OS. These short-term prognostic variables are similar to those reported for this group of patients in other European countries and in the USA.

Primary anorectal melanomas: an istitutional experience

Primary melanomas (M) of the rectum and anal canal are a rare pathological event, constituting approximately 1% of all invasive tumors in this site. From January 1973 to December 1990 at the Istituto Nazionale per lo Studio e 1a Cura dei Tumori of Milan, 11 patients were treated for M (5 males and 6 females), with a mean age of 60 years (range 40-80). The site of origin of the M was rectal in four patients, anal in five patients and in the anorectal joint in two patients. The lesion was prevalently polypoid and the average size was 4 cm (1-7.5 cm). Symptoms referred by the patients were rectal bleeding and tenesmus. In one patient the diagnosis was made after biopsy of an inguinal metastatic lymphnode. Of the 11 patients, six underwent curative resection (four Miles' resections and two local excisions). One patient is still alive with no evidence of disease after 120 months. The remaining five patients were submitted to palliative treatment, due to the presence of metastases in four of them and to age and general conditions in one. All of these patients died at 1, 2, 4, 5, and 6 months (median: 4 months). Overall median survival was eight months: 20 months in the radically treated group and four months in the palliatively treated group. Our data are in agreement with those reported in literature and confirm the prognostic severity of anorectal M due both to late diagnosis and the biological aggressiveness of the neoplasm.

Using the hypertext software to develop computer-assisted instruction in oncology for medical students

A new development in computer-assisted medical education has been the introduction of hypertext authoring systems. Authoring systems are computer programs that can allow an instructor to prepare computer-based medical educational materials without the need to know programming languages. Hypertext is a database management system that lets the user connect screens of information using associative links. The authors developed a hypertext authoring system for teaching their medical students the domain of oncology. The features of the system are hierarchical structure, index browsing, and nonsequential browsing. Moreover, the student may become a writer of a hyperdocument by typing a few script commands. In this way the hierarchical structure of a document meets the needs of the reader. Although hypertext brings with it a few difficulties for the student, the authors expect that the system will become a popular mean for organizing textual information for retrieval and browsing in oncology.

Sources of diagnostic discrepancies in fine-needle aspiration of the breast

Fine-needle aspiration (FNA) is a valuable technique to use in the evaluation of breast lesions; however, inadequate and discrepant diagnoses do occur. To identify the source and nature of inaccuracies related to the method we studied 39 cases in which FNA posed diagnostic problems. These problems could be attributed to sampling errors (71.8%), to the criteria of adequacy we use at our institution (25.6%), and to interpretation (2.6%). The nature of the breast lesion (68%) was the most common cause of inadequate sampling, followed by the experience of the aspirator (32%).

Radical consequence in the sexuality of male patients operated for colorectal carcinoma

Sixty sexually-active male patients affected by colorectal cancer and surgically treated at the Department of Surgery at University of Patras between 1981 and 1987 were interviewed by structured questionnaire to evaluate the etiology of sexual dysfunction. Patients were divided into three groups: (1) 20 patients, mean age 60.5 years (range 39-70), subjected to high anterior resection for carcinoma of the sigmoid colon (not lower than 18 cm from the anal margins, 1.2% Dukes' A, 31% Dukes' B, 67.8% Dukes' C); (2) 20 patients, mean age 62.4 years (range 43-70), subjected to low anterior resection (not more than 8 cm from the anal margins, 3% Dukes' A, 36% Dukes' B, 61% Dukes' C); and (3) 20 patients, mean age 59.75 years (range 27-70), subjected to abdominoperineal surgery (Miles' technique) in whom the malignancy was in the distal rectum (8% Dukes' A, 32% Dukes' B, 60% Dukes' C). The first group served as the control. All the anastomoses in the low anterior resection group were performed by manual suture. Statistical evaluation of the three groups was by the chi 2-test. The form of sexual dysfunction, (1) cessation of sexual relationship, (2) absence of erection, (3) impossible penetration or (4) absence of ejaculation, varied according to the type of operation, the frequency of each form being 5%, 5%, 30%, 20% for the high anterior resection, 65%, 45%, 60%, 50% for Miles' operation and 20%, 25%, 45%, 5% for the low anterior resection respectively.

Comparison of nutritional status after total or subtotal gastrectomy

Forty-four disease-free patients were evaluated a mean of three years after total gastrectomy (TG) or subtotal gastrectomy (SG) for cancer. The investigation encompassed nutritional assessment by standard anthropometric and biochemical indices; evaluation of the nutritional intake based on 24 h recall and of appetite status on a visual analogue scale; and anamnestic analysis of postcibal symptoms and syndromes. Body weight had declined progressively until the 15th postoperative month after both TG and SG. Weight loss, as well as the general nutritional status index (actual body weight/usual body weight +/- actual body weight/desirable body weight + measured arm muscle circumference/reference arm muscle circumference x 33), had dropped more significantly in patients undergoing TG than those having SG (p less than 0.05). The principal body compartment change was observed in the fat content which was severely depleted, whereas the somatic proteins were relatively spared and the visceral proteins and remaining biochemical variables were in the normal range. Protein intake was not significantly different in the two groups, but caloric intake was significantly lower and the number of meals significantly higher after TG (p less than 0.05). These data suggest that malnutrition after TG is relatively mild and that this operation causes only a limited impairment of the nutritional state, and spares most of the nutritional variables of clinical interest in comparison with SG. These findings argue in favor of TG when clinically indicated without excessive concern about postoperative nutrition.

A clinicopathologic study of primary hepatic carcinoid tumors

Six cases of primary hepatic carcinoid tumors were studied with combined immunocytochemical and electron microscopic techniques. Positive tumor immunostaining with PHE5, LK2H10, neuron-specific enolase (NSE), serotonin, gastrin, and insulin antibodies was observed. At the ultrastructural level, cytoplasmic dense granules were seen in all the cases tested. This finding supports a putative origin of these carcinoids found in the liver from a pluripotential stem cell. The clinical course and follow-up of these cases suggests that this unusual hepatic neoplasm has a more favorable prognosis than other forms of hepatic cancer.

A clinicopathologic study of primary hepatic carcinoid tumors

Six cases of primary hepatic carcinoid tumors were studied with combined immunocytochemical and electron microscopic techniques. Positive tumor immunostaining with PHE5, LK2H10, neuron-specific enolase (NSE), serotonin, gastrin, and insulin antibodies was observed. At the ultrastructural level, cytoplasmic dense granules were seen in all the cases tested. This finding supports a putative origin of these carcinoids found in the liver from a pluripotential stem cell. The clinical course and follow-up of these cases suggests that this unusual hepatic neoplasm has a more favorable prognosis than other forms of hepatic cancer.

The role of CEA and liver function tests in the detection of hepatic metastases from colo-rectal cancer

Carcinoembryonic antigen and some liver function tests (alkaline phosphatase, gamma-glutamyltranspeptidase, lactic dehydrogenase and cholinesterase) were evaluated in patients with primary colorectal cancer in order to define their role in the pre-operative detection of liver metastases. The records of 278 consecutive patients admitted to the Istituto Nazionale Tumori of Milan between January 1982 and December 1983 who were suffering from primary invasive colo-rectal cancer and who underwent laparotomy were retrospectively analyzed. At laparotomy, liver metastases were found in 38 pts (13.7%). Considering single tests, CEA was the most sensitive (71%); no single test was found to be reliably predictive, when the result was abnormal. On the contrary, the normal value of each test was associated with a good prediction. When we considered all the five tests together in the single patient their predictive value, when abnormal, proved to be quite good only if four or five results were abnormal. On the other hand, liver metastases in the presence of all normal tests were found only in two patients, so giving a negative predictive value of about 97%. So we conclude that, in the lack of an infallible imaging technique for liver evaluation, in the presence of all normal tests any other investigation on the liver could be avoided. However, when liver tests are pathologic, some other imaging technique should be performed in order to supply the surgeon with information about the extent and the spread of the metastases.