Prospective, multicenter study on non-pharmacological, patient related predictive factors of chemotherapy induced nausea and vomiting (CINV): A NOGGO-EMRISK trial

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Background: Despite many years of clinical research and development, nausea and vomiting remain challenging toxicities related to chemotherapy. The aim of our study was assessment of non-pharmacological, patient-related risk factors for chemotherapy-induced nausea and vomiting and development of unique predictive score in patients with gynaecological malignancies planned for chemotherapy. Methods: A research-based questionnaire of 27 risk factors was generated and provided to patients diagnosed with gynaecological malignancies prior to indicated chemotherapy. The data on nausea and vomiting from at least 3 cycles therapy was collected. Variable selection via stepwise and LASSO regression combined with patients history was used to identify a small set of questions with high predictive power. As risk prediction model, a Bayesian logistic regression was implemented with a cut-off chosen to yield a sensitivity of 80%. Area under the curve analysis (AUC) was conducted, and accuracy of prediction was calculated. Results: In total 191 patients were enrolled. The most frequent diagnosis and chemotherapy was ovarian cancer (69%) and carboplatinum/paclitaxel combination (57.7%), respectively. Six factors (emetogenic potential of the therapy, educational status, nausea and vomiting due to other medication, motion sickness, anxiety from therapy in general and anxiety from nausea due to therapy) were identified as most important predictive factors. All questions were answered by 132 (69.1%) patients. Among those 97 (68%) reported nausea or vomiting. The AUC of the predictive score consisting mentioned factors was 0.741, with a sensitivity of 80.4%, specificity of 51.4% and an overall accuracy of 72.7%. Conclusions: Patients related risk factors are missing in selection of the antiemetic prophylaxis in patients under chemotherapy. Presented predictive score showed very promising predictive power and is going to be validated in further phase of the trial. Clinical trial information: DRKS-ID: DRKS00015151.

Efficacy of Endocrine Therapy for the Treatment of Breast Cancer in Men: Results from the MALE Phase 2 Randomized Clinical Trial

Importance

The extent of changes in estradiol levels in male patients with hormone receptor-positive breast cancer receiving standard endocrine therapies is unknown. The sexual function and quality of life related to those changes have not been adequately evaluated.

Objective

To assess the changes in estradiol levels in male patients with breast cancer after 3 months of therapy.

Design, Setting, and Participants

This multicenter, phase 2 randomized clinical trial assessed 56 male patients with hormone receptor-positive breast cancer. Patients were recruited from 24 breast units across Germany between October 2012 and May 2017. The last patient completed 6 months of treatment in December 2017. The analysis data set was locked on August 24, 2018, and analysis was completed on December 19, 2018.

Interventions

Patients were randomized to 1 of 3 arms: tamoxifen alone or tamoxifen plus gonadotropin-releasing hormone analogue (GnRHa) or aromatase inhibitor (AI) plus GnRHa for 6 months.

Main Outcomes and Measures

The primary end point was the change in estradiol levels from baseline to 3 months. Secondary end points were changes of estradiol levels after 6 months, changes of additional hormonal parameters, adverse effects, sexual function, and quality of life after 3 and 6 months.

Results

In this phase 2 randomized clinical trial, a total of 52 of 56 male patients with a median (range) age of 61.5 (37-83) years started treatment. A total of 3 patients discontinued study treatment prematurely, 1 in each arm. A total of 50 patients were evaluable for the primary end point. After 3 months the patients' median estradiol levels increased by 67% (a change of +17.0 ng/L) with tamoxifen, decreased by 85% (-23.0 ng/L) with tamoxifen plus GnRHa, and decreased by 72% (-18.5 ng/L) with AI plus GnRHa (P < .001). After 6 months, median estradiol levels increased by 41% (a change of +12 ng/L) with tamoxifen, decreased by 61% (-19.5 ng/L) with tamoxifen plus GnRHa, and decreased by 64% (-17.0 ng/L) with AI plus GnRHa (P < .001). Sexual function and quality of life decreased when GnRHa was added but were unchanged with tamoxifen alone.

Conclusions and Relevance

This phase 2 randomized clinical trial found that AI or tamoxifen plus GnRHa vs tamoxifen alone led to a sustained decrease of estradiol levels. The decreased hormonal parameters were associated with impaired sexual function and quality of life.

Trial Registration

ClinicalTrials.gov Identifier: NCT01638247.

Patient reported outcome and cosmetic evaluation following implant-based breast-reconstruction with a titanized polypropylene mesh (TiLOOP® Bra): A prospective clinical study in 269 patients

INTRODUCTION

Implant-based or expander-supported breast reconstruction is an established surgical method after mastectomies due to cancer or to prophylactic reasons. Patient reported outcome (PRO) and cosmetic outcome after breast reconstruction with a synthetic surgical mesh was investigated in a prospective, single-arm, multi-center study.

MATERIAL AND METHODS

Primary or secondary implant-based breast reconstruction with support of TiLOOP® Bra was performed in 269 patients during the PRO-BRA study. PRO 12 months after breast reconstruction was evaluated using Breast-Q questionnaire. Cosmetic outcome was evaluated by two independent experts by means of pictures taken preoperatively and at the follow-up visits.

RESULTS

Breast-Q and 12 months FU were completed by 210 women. Patients without adverse event had a significantly higher Breast-Q score for "sexual well-being" (p = 0.001); "psychosocial well-being" was negatively influenced by prior therapies (p < 0.01), and older patients had significantly lower scores at 12 months FU compared to pre-OP for "satisfaction with breasts" (p < 0.01) while the opposite was true for younger patients. Unilateral surgery resulted in reduced "satisfaction with breast" at 12 months FU (p < 0.01). Radiotherapy negatively influenced "satisfaction with breast", "sexual well-being" and "physical well-being chest". The cosmetic evaluation showed a significant difference (p < 0.001) in the evaluation by the patients and experts with the patients' assessment being worse compared to experts' assessment.

CONCLUSION

Our study showed that two years after implant-based breast reconstruction with support of TiLOOP® Bra PRO is influenced by different factors. This information can be used to improve the decision-making process for women who chose implant-based breast reconstruction.

[Criteria of life quality after reconstructive breast cancer surgery]

PURPOSE

The aim of this study was to evaluate the quality of life of women after a breast cancer surgery. The question was if women which had reconstructive breast cancer surgery experience a higher quality of life than women who, for various distinct reasons, had not undergone reconstruction.

PATIENTS AND METHODS

The participants of this study were women who had either received a mastectomy or those who at the same time underwent a breast reconstruction using implants during the time period from 1/1/2000 until 31/10/2003 at the University Hospital for Women of Heidelberg and Mannheim. With the help of three standardised questionnaires, the women could describe their post-surgical physical and psychological condition as well as the perceived quality of life. The study included 33 patients who had received breast implants and 31 patients without reconstruction.

RESULTS

Women who had breast cancer surgery with reconstruction through implants had less problems and restrictions concerning their physical condition as well as their functional status. Moreover, compared to those participants with no reconstruction, their cognitive and emotional burdens were not as pronounced and they also they were able to better cope with the disease. Thus, their overall quality of life was superior than that of the other women.

CONCLUSION

Breast reconstruction after primary and secondary mastectomy is an important contribution in order to improve the self-esteem and quality of a patient's life. Furthermore, it plays an essential role in coping with the psychological effects of breast cancer.

Only grading has independent impact on breast cancer survival after adjustment for pathological response to preoperative chemotherapy

Our objective was to determine pretreatment factors with an independent impact on survival after adjusting for response to preoperative chemotherapy and to describe parameters predictive for achieving a pathological complete remission (pCR) after preoperative chemotherapy containing an anthracycline. We performed univariate and multivariate analyses to describe the impact of the following pretreatment characteristics of 240 primary breast cancer patients who received preoperative chemotherapy containing an anthracycline at our institution on disease-free survival (DFS), distant disease-free survival (DDFS) and overall survival (OS): age, stage, clinical tumor size, clinical nodal status, grading, and expression of estrogen receptor, progesterone receptor, Her2/neu, Ki67, Bcl-2 and p53. Afterwards, the response to preoperative chemotherapy was added to the multivariate model in order to evaluate which pretreatment parameters retained their prognostic impact. In addition, univariate analysis was performed to describe pretreatment variables predictive for achieving a pCR. With a median follow-up of 6.4 years (range 0-10.4), only grading retained its independent impact on DFS, DDFS and OS [hazard ratio (HR) 1.5, 1.7 and 2.9, respectively; p<0.05] after adjusting for the strongest independent prognostic factors pathological T category at surgery (HR 1.6, 1.8 and 1.7, respectively; p<0.001) and pathological N category at surgery (HR 2.3, 2.4 and 2.1, respectively; p<0.001). Predictive factors for the achievement of pCR (p<0.05) were age under 35 years, lower stage or smaller clinical tumor size and higher expression of Bcl-2 at diagnosis. We conclude that only grading retained its independent prognostic impact on DFS, DDFS and OS after adjusting for pathological response of breast tumor and axillary lymph node metastases to preoperative chemotherapy. According to our data, it could be hypothesized that young patients with early tumor stage and small primary tumors might profit most from preoperative chemotherapy.

Lebensqualitätsverbesserung nach Mammareduktionsplastik

PURPOSE

Within this study the improvement of life quality in patients after surgery for breast reduction should be evaluated.

MATERIAL AND METHOD

In total 70 patients, who had undergone an operation for breast reduction in the University Women's Hospital of Heidelberg from May 1998-June 2000, were chosen for this study. They were invited to an interview with three different standardized questionnaires concerning life quality. In total the questionnaires of 37 patients could be evaluated. They were about 12 months after operation.

RESULTS

It could be shown, that all patients had a significant improvement of their functional symptoms, the main part of them were totally free of symptoms after the operation. Most patients felt more female than before. They regarded themselves as more active, productive and sociable. This resulted in an improved self-confidence. In both groups the improvement was based mostly on a release of their functional complaints such as pain in th back or in the shoulders, but also on the psychological relief of the physical shame. The reduction of the breast masses, which were before well hidden by clothes, led to an improved self-confidence and self-assurance.

CONCLUSION

Either women, who underwent the operation due to medical reasons, as well as women, who had mainly esthetic reasons for the operation, reach an improvement of life quality after surgery. The reached satisfaction of the patients and the improvement of life quality were absolutely independent from the weight of the resected tissue.

[Value of radiotherapy in breast cancer. Breast preservation rises to 80%]

The indication for radiotherapy for mamma carcinoma is determined in particular by the macroscopic and microscopic tumor findings, the number of lymph nodes identified, receptor status, the surgical report and (neo)adjuvant chemotherapy. Irradiation is applied in particular in conjunction with breast-preserving first-line treatment in the case of ductal in situ carcinomas, and postoperatively following breast conservation in the case of invasive mamma carcinoma. The indication for irradiation following mastectomy is controversial and is determined by tumor size and location, together with further factors (see the Guidelines of the German Society of Senology). The indications applying to the irradiation of regional lymph nodes are determined by the sites of the respective metastases. The combination of radio- and chemotherapy is carried out in close cooperation between oncologists and radiologists.

[Surgical therapy of breast carcinoma. Much of the fright is lost]

Ever since breast cancer has become looked upon as a local and simultaneously a systemic disease, local treatment has become ever less radical. Today, some 70% of all mamma carcinomas can be treated with breast-preserving techniques. Following pre-operative downstaging by primary neoadjuvant chemotherapy, even the majority of large tumors can be managed with conservative surgery. With the exception of ductal carcinoma in situ (DCIS) axillary lymph node clearance is currently standard practice. For an assessment of nodal status, at least 10 lymph nodes must be obtained and examined histologically. The sentinel lymph node biopsy performed under study conditions should be left to experienced specialized centers. Postoperative irradiation of the preserved breast is an element of the overall concept of breast-preserving surgery. The spectrum of surgical options covers breast-preserving procedures, skin-preserving mastectomy and amputation, which cannot always be avoided. With regard to plastic reconstruction, a differentiation should be made between the possibilities for reconstruction during primary surgery and reconstruction at a later date. Since postoperative radiotherapy can considerably diminish the results of reconstruction, current tendency is towards secondary reconstruction.

Complete recovery after 2 h of cardiopulmonary resuscitation following high-dose prostaglandin treatment for atonic uterine haemorrhage

We report the case of a 31-year-old woman who delivered twins by Caesarean section in whom atonic uterine haemorrhage developed 6 h postoperatively. During conservative treatment with the high-dose prostaglandin analogs sulprostone (PGE(2)) and dinoprost (PGF(2alpha)), acute pulmonary oedema and cardiac decompensation developed and, subsequently, the patient suffered cardiopulmonary arrest. After a 2h-period of cardiopulmonary resuscitation (CPR), it was possible to restore and stabilize circulation under the highest dose of catecholamines. Despite 2h of CPR, the patient was discharged from hospital 3 months later without any major physical or neurocognitive deficit.

A new noninvasive approach in breast cancer therapy using magnetic resonance imaging-guided focused ultrasound surgery

An ideal vision of modern medicine includes tumor surgery with the human body remaining completely intact. A noninvasive therapy could avoid infections and scar formation; it would require less anesthesia, reduce recovery time, and possibly also reduce costs. This study investigated whether human breast cancer can be effectively treated with a novel combination of image guidance and energy delivery, noninvasive magnetic resonance imaging (MRI)-guided focused ultrasound (FUS). We have developed a FUS therapy unit guided by MRI for the treatment of human breast tumors in a clinical 1.5 T MR scanner. With interactive target segmentation on MRI, defined volumes could be noninvasively treated in a single session with on-line MR temperature control. The ultrasound waves were focused through the intact skin and resulted in the localized thermal tissue ablation at a maximum temperature of 70 degrees C. The therapy principle was first demonstrated in sheep breast in vivo and was then applied in a patient with core biopsy-proven invasive breast cancer 5 days before breast-conserving surgery. MRI proved suitable to delineate the breast cancer, served as stereotactic treatment planning platform, and delineated the FUS-related tissue changes such as interruption of tumor blood flow. Furthermore, MRI localized the hot spot in the tumor and measured temperature elevation during the treatment. This allowed us to monitor the efficacy and safety of FUS therapy. Immunohistochemistry of the resected specimen demonstrated that FUS homogeneously induced lethal and sublethal tumor damage with consecutive up-regulation of p53 and loss of proliferative activity. This effect was realized without anesthesia and damage to the surrounding healthy tissue or systemic effects. Overall, our results show that noninvasive MRI-guided therapy of breast cancer is feasible and effective. Thus, MRI-guided FUS may represent a new strategy for the neoadjuvant, adjuvant, or palliative treatment in selected breast cancer patients and in patients with other soft-tissue tumors.

Urokinase and plasminogen activator-inhibitor (PAI-1) status in primary ovarian carcinomas and ovarian metastases compared to benign ovarian tumors as a function of histopathological parameters

Ninety-eight patients with histologically confirmed ovarian tumors (77 primary ovarian carcinomas of stages T1 to T3 according to the postoperative histopathological classification pTNM classification, 14 ovarian metastases of various origins and seven benign ovarian tumors) were investigated with regard to the concentration of urokinase-type plasminogen activator (uPA) and plasminogen activator inhibitor (PAI-1) in membrane extracts of tumors. The results were correlated with the clinical course and with histopathological findings. With more advanced stage of primary ovarian carcinomas, there was a highly significant rise in the membrane concentrations of both uPA and PAI-1. However, increasing dedifferentiation of the tumors correlated only with uPA, but not with PAI-1. There was no correlation between the number of steroid receptors for estradiol and progesterone and the content of uPA or PAI-1 in the primary ovarian carcinomas. In the 14 ovarian metastases of different origins incluced in the study, the contents of uPA and PAI-1 were comparable to those of primary ovarian carcinomas. Compared with the malignant ovarian tumors, the median uPA and PAI-1 concentrations in the membrane fraction were 2.5-6 fold lower (highly significant) in the group of seven benign tumors. A cut-off value of 4.8ng/mg pellet protein for a prognostically favorable (< 4.8) or unfavorable course (> 4.8) could be determined for uPA (p = 0.0392) but not for PAI-1 on the basis of the Kaplan and Meier survival curves in the malignant primary ovarian carcinomas.

[Quality of life of over 60-year-old patients with breast and uterine carcinoma, 5 years after primary operation]

In the 5-year follow-up period, we studied the quality of life of 145 patients who were at least 60 years old at the time of primary operation. Of the patients, 70 women had breast cancer and 75 endometrium cancer. We used the questionnaire "short form health survey: medical outcomes study". The areas which were analyzed were stress due to therapy, body image/femininity and social contacts. The Karnofsky-Index was determined by the physician. In both groups, most stress was felt due to the operation and at the first knowledge of the diagnosis. In the area of emotional stress 1/3 of the patients of both groups declared continuous stress due to feelings of fear, helplessness and passivity. In the area of body image/femininity half the patients with breast cancer and 2/3 with endometrial cancer felt stress. In the area of social contact 2/3 of the patients felt uncertainty in contact with others and this led to social retreat in 1/3 of the women. The Karnofsky-Index of all patients was between 50-100%. Our study supports the view that older patients with cancer should also be offered psychosocial counseling.

Measuring the thickness--is that all we have to do for sonographic assessment of endometrium in postmenopausal women?

For sonographic assessment of the endometrium in postmenopausal women, measurement of the maximum thickness is used in many cases as the sole criterion. The cut-off values stated in the literature, however, vary considerably. This prospective study examined 200 female patients in order to ascertain the value of echomorphology in addition to endometrial biometry. Up to an overall endometrial thickness of 3 mm, we observed only histologies without any pathological findings, whereas from an endometrial thickness of 10 mm upwards, only polyps, hyperplasias and carcinomas were found. In more than a third of our patients, the endometrial thickness was between 3 and 10 mm where the structure of the endometrium could reflect the possible histological finding: homogeneity, low echo and a sonographically depictable central echo between symmetrical endometrial leaves were an indication for absence of pathological findings, whereas heterogeneity and high echogenicity were pointers for pathological changes. In contrast to the sole measurement of endometrial thickness in the postmenopause, the combined metric and morphological parameters improve not only the predictability of pathological findings but, above all, the selectivity of the vaginosonographic assessment of the endometrium in postmenopausal women.

[Ultrasound assessment of the postmenopausal endometrium. Is measuring thickness adequate?]

Sonographic assessment of the endometrium in postmenopausal women is generally based on total thickness as only criterion. The cut-off values recommended in literature, however, vary considerably. The purpose of this study was to examine the significance of sono-morphology besides biometry of the endometrium. If vaginosonography showed an endometrial thickness of 3 mm or less, all histological findings were inconspicuous; beginning at a thickness of 10 mm only hyperplasias, polyps and carcinomas were found. In the range between, including more than one-third of our patients, the structure can point out the type of histology: Homogeneity, low echogeneity and a median echo are not important findings, but inhomogeneity and high echogeneity point to pathological changes of the endometrium. Using combined, metric-structural criteria in vaginosonography of the endometrium, not only the predictivity, but above all the selectivity is improved.

[Marshall-Marchetti-Krantz operation or fasciaplasty in therapy of recurrent urinary incontinence in women]

In this study, a follow-up examination was carried out, comprising 59 female patients who were operated between the years 1985 and 1991 because of recurrent urinary incontinence. We distinguished two different operating methods: 34 women were treated following the Marshall-Marchetti-Krantz operation technique, whereas a fasciaplasty-suspension was employed om 25 patients. At the urodynamic follow-up examination, the patients had experienced an average history of 2 years' recurrent urinary incontinence. The patients' subjective observation of anamnestic urinary incontinence was objectified by a clinical cough test, cystotonometry and sonography of the small pelvis. Making extensive use of the urodynamic examination possibilities showed a 79.4% improvement following the Marshall-Marchetti-Krantz operation in comparison to a 52% improvement after the fasciaplasty operation. The operations success is assessed by evaluation of the depression quotient. Here the Marshall-Marchetti-Krantz operation resulted in a significant improvement. After the fasciaplasty operation, however, this was not found to be the case.

[D-dimer and plasminogen activator of the urokinase type: personal experiences with breast cancer]

Plasma values of d-dimer, a stable end product of plasmin-induced fibrinolysis, were ascertained in 128 female patients with mammary carcinoma. These patients demonstrated significantly increased d-dimers in comparison with the control group with benign mammary disease (p < 0.01). The sensitivity and specificity of d-dimer were slightly higher than those of the established tumour marker CA 15-3 and CEA. There was no correlation between d-dimers in the plasma and increased expression of urokinase plasminogen activator (UPA) in the tissue. Increased d-dimers in the plasma of female patients with mammary carcinoma reflect multi-factoral interactions between carcinoma growth and the haemostatic-fibrinolytic system, and may be used as tumour markers.

[Diagnosis of local panarteritis nodosa of the uterine cervix]

A 44-year old woman was referred because of metrorrhagia and asthenia. A diagnosis of uterine malignancy was suspected on the basis of the management of the Cervix uteri and an elevated erythrocyte sedimentation rate. Conisation and hysterectomy were performed, and histological examination revealed necrotising vasculitis affecting the Cervix uteri. Corpus uteri, muscle and fat biopsies showed no Periarteritis nodosa lesions. The incidental finding of necrotising arteritis in a surgical uterine specimen, involves further study to exclude systemic disease. The ability to involve any organ in the body makes it possible for specialists in every branch of medicine to be involved in the management and care of these patients.

[Infected chorionic hematoma as a cause of infection in the 2nd trimester]

Superinfected subchorionic haematomas are a rare septic focus in the 2nd trimenon. Symptoms being unspecific, the diagnosis has to be made by exclusion, in most cases. As the changes of a successful treatment of the manifest infection is poor, antibiotic prophylaxis as well as close laboratory controls and early antibiotic therapy should be discussed after sonographic diagnosis of an intrauterine haematoma. Two of our three patients reported on having suffered a miscarriage; only one pregnancy could be maintained after spontaneous depletion of the infected haemorrhage.

[Fetal outcome of premature infants less than 1,500 g birth weight with special reference to surfactant requirements]

The objective of our study was to examine therapeutic success within a study group of 108 premature babies weighing less than 1500 g at birth. The foetal outcome was divided according to intrauterine betamethasone administration, method of birth and surfactant requirement. 59 of the babies did not require a surfactant factor, because within 12 hours it was possible, to reduce respiration to an O2 partial pressure of 20%. In 49 of the premature babies, this was not possible, and therefore, surfactant substitution was required, whereby this subject group was divided into surfactant responders and surfactant non-responders. In addition, we examined the influence of the method of birth on later survival and the occurrence of intraventricular haemorrhages in the children. A noticeably higher survival rate was determined in 81% of the children, born via Caesarean section, compared with 63% of premature babies, born via vaginal delivery. Likewise, detectable intraventricular haemorrhages (IVH) were significantly lower amongst premature babies delivered via Caesarean section (25%) than those delivered vaginally (37.5%). A considerable improvement in survival rates and a reduction in IVH was achieved by means of completed lung maturation with betamethasone (16 mg in 48 hours). 62% of premature infants with completed prepartal lung maturity did not require the administration of a surfactant due to the favourable respiratory situation. However, for those cases, where it was no longer possible to conduct lung maturation, only 46% did not require surfactant substitution. Therefore, it would appear advisable, to delay the delivery of premature babies weighing less than 1500 g in order to carry out lung maturity treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

[Struma carcinoid tumor within a dermoid cyst as an incidental finding in cesarean section]

A 25-year-old primigravida with breech presentation was admitted near term. During Caesarean section, a dermoid cyst of the right ovary was detected. The dermoid cyst was enucleated, preserving a plum-sized ovary. Histology revealed a strumal carcinoid within the excised dermoid cyst. From the histological point of view it was classified as a tumour of low malignancy. The clinical study provided no evidence of any metastases. On the 14th postoperative day the patient could be discharged from hospital subject to close aftercare control.