Opioids in advanced cancer: use, storage and disposal in the home

OBJECTIVES

To determine the patterns of storing, using and disposing of opioids among patients with advanced cancer followed at home.

METHODS

Patients who were prescribed opioids were selected. Prescribed opioids and their doses used for background pain and breakthrough pain were collected, as well as CAGE (cut down, annoyed, guilty and eye opener) for alcohol and drugs, smoking and history of illicit substance use. Questions regarding the opioid use, storage and disposal were posed.

RESULTS

100 patients were surveyed. Fifty-one patients had unused opioids at home, 25 patients did not throw away the drugs, 40 patients saved opioids for future use and 35 patients were unaware of proper opioid disposal methods. A total of 28 patients reported unsafe use by sharing or losing their opioids; 12 patients were unaware that their opioid could be fatal when taken by others. Most patients acknowledged that pain medications could be dangerous when taken by others. Patients with a partner and who were married were more likely to keep their opioids locked (p=0.028 and p=0.025, respectively).

CONCLUSION

A large number of patients with advanced cancer followed at home do not store, use and dispose of opioids safely. Patient education programmes should be incorporated to decrease the availability of opioids at home for abuse, diversion, and accidental poisoning.

International survey of human herpes virus 8 screening and management in solid organ transplantation

BACKGROUND

HHV-8/Kaposi Sarcoma herpesvirus has been associated with a broad spectrum of diseases in solid organ transplant (SOT) recipients. Primary donor-derived infection can be associated with severe and rapidly fatal non-neoplastic disease, and diagnosis is made with high HHV-8 DNAemia.

METHODS

We carried out an international survey to investigate the current approach to HHV-8 screening, and management in SOT since a protocol has not been established by international guidelines.

RESULTS

A total of 51 transplant centers from 15 countries filled out the survey. HHV-8-associated diseases in SOT have been diagnosed during the previous 5 years in 67% of centers. Pretransplant serological screening is performed in 17 centers (33%), and posttransplant HHV-8 nucleic acid testing (NAT) monitoring is performed in 21 centers (41%). Performing HHV-8 NAT monitoring and serological screening were found associated with having diagnosed in the previous 5 years a non-malignant HHV-8-associated disease.

CONCLUSIONS

Serological pretransplant screening of donors and recipients and post-transplant HHV-8 NAT monitoring recommendations should be standardized. Even though serological assays are not optimal, they could contribute to increasing knowledge on epidemiology and management of HHV-8-associated diseases after SOT.

Physicians' Knowledge and Application of Immunization Strategies in Patients with Inflammatory Bowel Disease: A Survey of the Italian Group for the Study of Inflammatory Bowel Disease

BACKGROUND

No data on European countries about knowledge and application of immunization strategies in patients with inflammatory bowel disease (IBD) are available.

OBJECTIVES

We designed a questionnaire aimed at exploring these issues among Italian gastroenterologists dealing with adult and paediatric IBD.

METHODS

An anonymous, 24-item, questionnaire was sent via e-mail to all members of the Italian Group for the study of Inflammatory Bowel Disease. Three sets of questions were formulated: (1) Characteristics of respondents; (2) General opinions on the role of vaccines in IBD patients; (3) Immunizations of IBD patients in clinical practice.

RESULTS

Of the 455 total surveys sent, there were 198 respondents (response rate: 43.5%). The great majority of respondents (82.9%) reputed as "very important" to perform the vaccinations recommended by the guidelines in patients with IBD. The indication to immunization is given at the diagnosis of the disease by 55.6% of the respondents. The most frequently recommended vaccine in IBD patients is the annual flu vaccine, while the recommendation rate for the other vaccines is variable depending on the different pathogens.

CONCLUSIONS

Efforts carried out by the scientific societies are required to increase the awareness of this relevant topic among physicians.

Prospective Study on Incidence, Risk Factors and Outcome of Recurrent Clostridioides difficile Infections

Background: Limited and wide-ranging data are available on the recurrent Clostridioides difficile infection (rCDI) incidence rate. Methods: We performed a cohort study with the aim to assess the incidence of and risk factors for rCDI. Adult patients with a first CDI, hospitalized in 15 Italian hospitals, were prospectively included and followed-up for 30 d after the end of antimicrobial treatment for their first CDI. A case–control study was performed to identify risk factors associated with 30-day onset rCDI. Results: Three hundred nine patients with a first CDI were included in the study; 32% of the CDI episodes (99/309) were severe/complicated; complete follow-up was available for 288 patients (19 died during the first CDI episode, and 2 were lost during follow-up). At the end of the study, the crude all-cause mortality rate was 10.7% (33 deaths/309 patients). Two hundred seventy-one patients completed the follow-up; rCDI occurred in 21% of patients (56/271) with an incidence rate of 72/10,000 patient-days. Logistic regression analysis identified exposure to cephalosporin as an independent risk factor associated with rCDI (RR: 1.7; 95% CI: 1.1–2.7, p = 0.03). Conclusion: Our study confirms the relevance of rCDI in terms of morbidity and mortality and provides a reliable estimation of its incidence.

How can we optimise antifungal use in a solid organ transplant centre? Local epidemiology and antifungal stewardship implementation: A single-centre study

PURPOSE

We aimed to implement and to assess the impact of the antifungal stewardship programme (AFSp) on prescription appropriateness of antifungals, management and outcomes of candidaemia patients, and antifungal consumption and costs at our solid organ transplant (SOT) institute.

METHODS

Local epidemiology of invasive fungal infections (IFIs) from 2009 to 2017 was analysed in order to prepare an effective AFSp, implemented in January 2018. It included suspension of empirical antifungal prescriptions after 72 hours (antifungal time-out), automated alert and infectious disease (ID) consult for empirical prescriptions and for every patient with IFI, and indication for step-down to oral fluconazole when possible. We used process measures and results measures to assess the effects of the implemented programme.

RESULTS

The ASFp led to significant improvements in selection of the appropriate antifungal (40.5% in pre-AFS vs 78.6% in post-AFS), correct dosing (51.2% vs 79.8%), correct length of treatment (55.9% vs 75%) and better management of patients with candidaemia. Analysis of prescribed empirical antifungal revealed that defined daily doses (DDDs) per 100 patient days decreased by 36.7% in 2018 compared to the average of pre-AFSp period, with important savings in costs.

CONCLUSION

This AFSp led to a better use of antifungal drugs in terms of appropriateness and consumption, with stable clinical and microbiological outcomes in patients with IFI.

Suboptimal performance of APRI and FIB-4 in ruling out significant fibrosis and confirming cirrhosis in HIV/HCV co-infected and HCV mono-infected patients

PURPOSE

We aimed to assess the diagnostic reliability of two indirect biomarkers, APRI and FIB-4, for the staging of liver fibrosis using transient elastography (TE) as reference standard, among HIV/HCV co-infected and HCV mono-infected patients.

METHODS

This is an observational, retrospective study on subjects who had access to the RESIST HCV from October 2013 to December 2016, a regional network encompassing 22 hospitals and academic centers throughout Sicily. Sensitivity, specificity and diagnostic accuracy of indirect biomarkers for liver stiffness measurement (LSM) < 9.5 kPa (significant fibrosis) and LSM ≥ 12.5 kPa (cirrhosis) were determined by receiver operator characteristics (ROC) curves.

RESULTS

238 HIV/HCV co-infected and 1937 HCV mono-infected patients were included. Performances of FIB-4 and APRI for the detection of significant fibrosis and cirrhosis proved to be unsatisfactory, with very high false negative and false positive rates among both cohorts. No significant differences were found after stratification of HIV/HCV co-infected patients for BMI < or ≥ 25, ALT < or ≥ 40 IU/L, ALT < or ≥ 80 IU/L, and presence/absence of a bright liver echo pattern on ultrasonography.

CONCLUSIONS

Differently from other studies, we detected the unreliability of APRI and FIB-4 for the assessment of liver fibrosis in both HCV mono-infected and HIV/HCV co-infected patients.

Behavioral and clinical characteristics of people receiving medical care for HIV infection in an outpatient facility in Sicily, Italy

AIM

The authors examined a cohort of HIV-positive outpatients at the AIDS Center of Palermo University in Italy in order to identify factors related to the frequency of their visits to the outpatient facility for health care services.

METHODS

Two hundred and twenty-four HIV-infected subjects were enrolled in the study. Demographic and HIV disease characteristics were recorded and assessed with the number of days accessed to our outpatients unit in univariate and multivariate analyses. The potential relationship with immunological status was also analyzed stratifying the patients into groups according to their CD4(+) T-cell counts (≥500 vs <500/mm(3), and ≥200 vs <200/mm(3)).

RESULTS

Both univariate and multivariate analyses showed that duration of antiretroviral therapy <5 years and hypertension were significantly associated with a CD4(+) T-cell count of <500/mm(3), whereas geographic origin (Africa) was associated with a CD4(+) T-cell count of <200/mm(3). Mean number of days the patients sought access to day-care services for laboratory tests was negatively associated with CD4(+) T-cell count.

CONCLUSION

Patients with low CD4(+) T-cell counts showed higher use of health care services, demonstrating how early HIV diagnosis can help to reduce health care costs. The CD4(+) T-cell cut-off of 200 cells emphasizes the importance of identifying and managing HIV infection among hard-to-reach groups like vulnerable migrants. In our sample, the illegal status of immigrants does not influence the management of their HIV/AIDS condition, but the lack of European health card that documents the current antiretroviral status, could interfere with the efforts to eradicate AIDS. A better understanding of the major determinants of HIV treatment costs has led to appropriate large-scale actions, which in turn has increased resources and expanded intervention programs. Further guidance should be offered to hard-to-reach groups in order to improve early AIDS diagnosis, and procedures for identifying and managing these vulnerable subjects should be made available to care commissioners and service providers.

Outcome and clinical-biological characteristics of patients with advanced breast cancer undergoing removal of ovarian/pelvic metastases

BACKGROUND

Patients with metastatic breast cancer to the ovary, without tumor debulking and after systemic therapy, have a 5-year survival rate < 10%.

PATIENTS AND METHODS

We analyzed a series of 37 patients, operated in one institution over 10 years, for both the primary tumor (PT) and ovarian/pelvic metastases (OPM). Estrogen receptors (ER), progesterone receptors (PgR), HER-2 and Ki-67 were determined.

RESULTS

Patients were predominantly young: 27 (73%) patients were < 50 years. Average ER/PgR expression did not change significantly between PT (mean ER = 66%, PgR = 35%) and OPM (mean ER = 67%, PgR = 28%). Median time to OPM was 42 months (range 0-176); 5-year OS after OPM was 51% (95% confidence interval 32% to 67%). When combining ER and PgR status, patients with ER > 50% on both PT and OPM and with PgR > 50% on PT and/or OPM (good prognosis, 11 patients) had a better outcome versus0 patients with ER and PgR ≤ 50% on both PT and OPM (bad prognosis, eight patients) and also versus the remaining patients (intermediate prognosis, 18 patients), P value = 0.010.

CONCLUSION

Patients with OPM from breast cancer show a favorable prognosis after tumor debulking, whether it was radical or not, especially when a high expression of ER and PgR is present in both PT and OPM.

Abstract PD10-07: Hormone-Receptor Expression and Activity of Trastuzumab-Based Therapy in HER2-Positive Advanced Breast Cancer Patients

Background: Hormone receptors (HR) and the human epidermal growth factor receptor 2 (HER2) are key biological factors in breast cancer. Gene expression profile studies indicate that HER2-positive/HR-positive and HER2-positive/HR-negative tumors fall into two distinct subtypes. These two subtypes carry a different prognosis in the absence of HER2-targeting. Furthermore, a relationship has been documented between increasing HR expression and reduced chemoresponsiveness. Despite these differences, HER2-positive abvanced breast cancer patients are usually treated with a unified approach of combining chemotherapy with an HER2-targeting agent, regardless of HR status. We studied the association between hormone receptor (HR) expression and the clinical outcome of women with HER2-positive advanced breast cancer receiving chemotherapy plus trastuzumab.

Methods: The effect of HR expression on overall response rate (ORR) and progression-free survival (PFS) to trastuzumab-based treatment was studied by univariate and multivariate analysis. HR positivity was defined as 1% or more tumor cells positive for the estrogen (ER) and/or for the progesterone (PgR) receptor by immunohistochemistry. For both ER and PgR, we studied different thresholds to identify levels of expression associated with the clinical outcomes of interest.

Results: 227 consecutive advanced breast cancer patients receiving trastuzumab plus chemotherapy between June 1999 and November 2008 at two Institutions were retrospectively analyzed. One hundred eleven patients (49%) had HR-positive tumors. Compared with low or no expression, high expression of ER (30% or more) predicted reduced probability of tumor response to trastuzumab plus chemotherapy (multivariate odds ratio 0.422, 95% confidence interval-C.I. 0.222-0.803, p = 0.009). In patients with HR-positive tumors the addition of maintenance endocrine therapy to trastuzumab after the completion of chemotherapy was associated with a significant increase in progression-free survival (hazard ratio-HR 0.521, 95% C.I. 0.3325-0.836, p = 0.007). Patients with HR-positive tumors not receiving maintenance endocrine therapy had similar PFS than patients with HR-negative tumors (HR 0.914, 95% C.I. 0.654-1.279, p = 0.601). In patients not receiving maintenance endocrine therapy, high ER expression (30% or more cells) was associated with non-significant trend towards reduced risk of progression, compared with patients with low or absent ER expression (HR 0.747, 95% C.I. 0.516-1.081, p = 0.122). Conclusions: Our results suggest a predictive role of HR expression in HER2-positive tumors. Further investigation in this patient subset is warranted to optimize the use of HER2-targeting agents, chemotherapy and endocrine therapy.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD10-07.

Abstract P6-11-14: Long-Term Disease Control with Vinorelbine, Cisplatin and Continuous Infusion of 5-Fluorouracil -ViFuP Regimen-in Metastatic Triple Negative Breast Cancer Patients

Background: Triple negative breast cancers (TNBCs) are characterized by lack of estrogen, progesterone, HER-2-neu receptors expression and comprise 15% to 20% of all breast cancers. Studies have suggested that

TNBCs may be more sensitive to DNA damaging agents like cisplatin. Our previous experience had identified a combination chemotherapy -the ViFuP regimen-with noteworthy efficacy and safety as a first or subsequent line treatment for metastatic breast cancer (MBC) patients (pts). In this view we retrospectively examined the activity of ViFuP regimen in 2 cohorts (A and B) of metastatic TNBC pts.

Material and Methods: From January 2000 to December 2008, 115 pts with MBC were treated with ViFuP regimen, at the European Institute of Oncology, Milan, Italy. Among these, 35 pts (30%) had TNBC. Pts received continuous infusion 5-fluorouracil 200 mg/m2/day, vinorelbine 20 mg iv on days 1 and 3 and cisplatin 60 mg/m2on day 1. Therapy was given every three weeks. In A 22 pts (63%) were triple negative on primary tumor and in B 13 pts (37%) were triple negative in metastatic site. Median age was 54 years (range 35-73), 11 pts (31%) were pre-treated for MBC and 21 pts (60%) had ≥3 metastatic sites.

Results: Thirty three pts were evaluable for response and 34 pts were assessable for toxicity. Median duration of treatment was 3.57 months (range 1-5.7). Four pts (12%) had complete responses, 14 pts (42%) had partial responses and 11 pts (33%) had stable disease with a clinical benefit (CB) of 73% (95% CI, 55%-87%). Four pts (12%) had progressive disease. Median time to progression was 6 months (95% CI, 5-8 months). Main toxicity was haematological with 62% of the pts showing grade 3/4 leuco-neutropenia. Alopecia was almost absent.

Discussion: Treatment with ViFuP regimen was effective and safe in metastatic TNBC providing long-term disease control in a high proportion of pts. The prolonged CB supports this regimen as an additional therapeutic opportunity in this category of pts.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-11-14.

Cisplatin, etoposide and continuous infusion bleomycin in patients with testicular germ cell tumors: efficacy and toxicity data from a retrospective study

We retrospectively reviewed medical charts of 54 patients who underwent orchidectomy for germ cell tumors (GCT) and received a regimen, given every 3 weeks, consisting of cisplatin 100 mg/m2 day 4 intravenous (i.v.), bleomycin 15 Units (U) day 1 i.v. push; bleomycin 10 U days 1-3 24 h i.v. continuous infusion (c.i.) and etoposide 100 mg/m2 days 1-5/i.v. (PEB). 53 of 54 patients achieved a complete remission without adjunctive surgery. At a median follow-up of 48.2 months (95%CI 41.7 - 54.8 months) all patients but one are alive with no evidence of disease recurrence. Patients receiving PEB experienced no pulmonary toxicity, nephrotoxicity nor neurological adverse events. PEB with c.i.bleomycin is an active regimen with a low rate of acute and late toxicity. The main limitations of our study are related to the retrospective analysis, the limited number of patients and the restricted follow-up time. A prolonged follow-up is necessary to evaluate long term toxicity and outcome.

Circulating endothelial cells (CECs), progenitors (CEPs), and circulating tumor cells (CTCs) for prediction of response in patients with advanced breast cancer (ABC) receiving metronomic oral vinorelbine (oV): Preliminary results

e14572

Background: Metronomic administration of chemotherapy given once or more per week with no extended gaps was shown to be effectively anti-angiogenic, causing growth arrest or apoptosis of endothelial cells in tumor neo-vessels. Preclinical and clinical studies indicate that ultra-low concentrations of various microtubule inhibitors inhibit proliferation or migration of endothelial cells. We investigated in a phase II study the activity of metronomic administration of oV in ABC, kinetics and response prediction of CECs, CEPs, CTCs and of other biomarkers of angiogenesis (soluble VEGF, VEGFr2, TSP1, bFGF). CT perfusion scans were also performed. Methods: From February 2008, 47 pts with ABC received oV (50 mg/die TTW). Currently 20 pts are evaluable for both activity and biomarker assessment. Baseline levels of biomarkers of angiogenesis were correlated with clinical response. Results: Shown in Table . Conclusions: We found that the baseline value of apoptotic cells (expressed as % of total cells) was significantly correlated with outcome. The baseline total, viable, and apoptotic CEC count and CTCs might provide an indirect measure for angiogenic turnover and an indicator of better response to anti-angiogenic therapy, supporting the use of metronomic treatments in patients expressing high levels of baseline CECs. Updated results will be presented together with correlation with perfusion CT scan and levels of CTCs.

[Table: see text]

No significant financial relationships to disclose.

Circulating tumor cells in operable breast cancer: a pilot study

Abstract #5028

Background. Circulating tumor cells (CTCs) in the peripheral blood are an ideal source for the detection of disseminated tumor cells because of an easy sampling procedure. Their prognostic significance has been demonstrated in metastatic breast cancer, while little data exist in operable patients. Aims of this study are the evaluation of the prevalence and kinetics of CTCs before and after surgical treatment and the possible correlation between CTCs and clinico-pathological characteristics and biological features. Methods. We analyzed 30 ml of peripheral blood from 60 T1-T3, any N, M0 breast cancer pts, before surgery and after 5 days. In case of positivity of one of the perioperative samples, a further sample was taken after 30 days. The presence of CTCs was assessed with the CellSearch System (Veridex, USA). Samples were subjected to immunomagnetic enrichment with an anti-Epcam-antibody: CTCs were defined as nucleated cells expressing cytokeratin 8, 18 and 19 but lacking CD45. A sample was considered positive when 1 or more cells were detected. Results. Data are available for 50 pts. We found ≥1 CTC in 28% of the pts (n=14/50) before surgery, and in 29% of the patients (n= 12/42 ) at 5 days. The median number of CTCs was 1, with a range of 1-3. We found a borderline significant association between the presence of CTCs at baseline and the presence of vascular invasion (p=0.09). The presence of CTCs at baseline did not correlate with tumor size (p=0.66), grading (p=0.88), presence of estrogens receptor (p=0.30), presence of progesteron receptor (p=0.30), HER2/neu status of the tumor (p=1.0), or with the presence of lymph node metastases (p=0.71). In 42 pts we have the data of CTCs determined at baseline and at day 5: 27 patients showed concordant results (23 negative and 4 positive). Among the 15 patients with different results, 8 were negative at baseline and positive at day 5: 6 out of the 8 patients had positive nodes. At day 30 we analyzed samples from 18 subjects: persistence of at least 1 CTC was found in 18 % of patients (n=5). Conclusions. The results of this explorative study are very preliminary and a larger number of patients and a long-term follow-up will be required. However, it is of interest the borderline correlation between presence of CTCs at baseline and vascular invasion, and between appearance of CTCs and nodal involvement in postoperative samples. The study is ongoing and the patients will be followed during and after adjuvant treatment to explore the prognostic significance of persistency of CTCs. Complete data will be presented.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5028.

Opinions concerning euthanasia, life-sustaining treatment and acceleration of death: results of an Italian Association of Medical Oncology (AIOM) survey

BACKGROUND

Advance directives, acceleration of death, euthanasia and 'life-sustaining treatment' have sparked much heated debate among the media, the public, doctors and political leaders. We evaluate the personal opinions of Italian Association of Medical Oncology (AIOM) members.

PATIENTS AND METHODS

A 30-item questionnaire was developed and delivered to all 1,832 AIOM members.

RESULTS

Six-hundred and eighty-five (37%) oncologists completed and returned the questionnaires. Sixty-three per cent felt culturally and psychologically prepared to face these issues. Fifty-four per cent believed that what had been decided while the patient enjoyed good health is no longer applicable in an advanced state of terminal illness. Thirty-nine per cent believed that doctors should abide by these directives, while 49% believed that this should be discussed on a case-by-case basis. Fourteen per cent of oncologists were favourable towards euthanasia and 42% only in particular circumstances. Fifty-six per cent had received at least one request for accelerating death: 15% consented, 50% discussed it with the patient and 31% refused.

CONCLUSION

Advance directives, euthanasia, accelerated death and life-sustaining treatment represent considerable challenges for Italian oncologists. Although prepared to face these issues, AIOM members ask for a debate within the medical world and for a shared judicial regulation.

Variation of circulating tumor cell levels during treatment of metastatic breast cancer: prognostic and therapeutic implications

BACKGROUND

This study aimed to evaluate the prognostic significance of circulating tumor cells (CTCs) detection in advanced breast cancer patients.

PATIENTS AND METHODS

We tested 80 patients for CTC levels before starting a new treatment and after 4, 8 weeks, at the first clinical evaluation and every 2 months thereafter. CTCs were detected using the CellSearch System.

RESULTS

Forty-nine patients had >or=5 CTCs at baseline. At the multivariate analysis, baseline number of CTCs was significantly associated with progression-free survival [hazard ratio (HR) 2.5; 95% confidence interval (CI) 1.2-5.4]. The risk of progression for patients with CTCs >or=5 at last available blood draw was five times the risk of patients with 0-4 CTCs at the same time point (HR 5.3; 95% CI 2.8-10.4). Patients with rising or persistent >or=5 CTCs at last available blood draw showed a statistically significant higher risk of progression with respect to patients with <5 CTCs at both blood draws (HR 6.4; 95% CI 2.8-14.6).

CONCLUSION

CTCs basal value is a predictive indicator of prognosis and changes in CTC levels during therapy may indicate a clinical response. Testing CTC levels during targeted treatments might substitute other measurement parameters for response evaluation.

Optimizing clinical care of patients with metastatic breast cancer: a new oral vinorelbine plus trastuzumab combination

BACKGROUND

Trastuzumab (T) combined with i.v. vinorelbine (i.v.VNR) is an active regimen for patients with advanced breast cancer (ABC). In order to further improve quality of life of patients undergoing treatment for ABC, a new regimen using oral vinorelbine (oVNR) (d1 + d3) plus q3wks T was tested (ToVNR).

PATIENTS AND METHODS

Thirty-nine patients with ABC, human epidermal growth factor receptor 2/neu 3+ or FISH positive received 288 treatment cycles with T 6 mg/kg (loading dose, 8 mg/kg) on d1 and oVNR 55 mg/m(2) on d1 + d3, q3wks until disease progression or unacceptable toxicity.

RESULTS

Thirty-seven patients and 286 treatment cycles were evaluated (two patients were lost to follow-up). Treatment was very well tolerated. Two patients had complete response (CR), 14 partial response (PR), 17 stable disease (SD) and four disease progression (PD) (overall response rate: 43%). Clinical benefit rate (CR + PR + SD >24 months) was 73%. Median time to progression was 8.9 months (range 2-27) and median duration of response was 10.9 months (range 2-27).

CONCLUSIONS

The ToVNR combination is active and very well tolerated. It favorably compares with the combination of T and weekly i.v. administered VNR, allowing a more convenient once every three weeks hospital admission and leaving patients and care providers free from the unpleasant effect of i.v.VNR.

Brain metastases in patients with advanced breast cancer

BACKGROUND

The incidence of brain metastases (BM) is apparently rising in patients with advanced breast cancer (ABC). We performed a case control study to define current features of breast cancer related to central nervous system (CNS) metastases.

PATIENTS AND METHODS

From March 1999 to May 2006, we identified 72 patients with symptomatic BM of breast cancer. A comparison group was randomly selected assigning to each case two patients with primary breast cancer and no BM, matched for year of diagnosis, age and tumour stage (pT status and nodal status).

RESULTS

Cases had a significantly higher rate of negative estrogen receptors (ERs) (60% in cases vs. 29% in controls), negative progesterone receptors (PgRs) (79% vs. 43%), HER2/neu over expression (44% vs. 13%) and immunostaining for Ki-67 > or =20% (84% vs. 55%), with p-value <0.001 for all four parameters in univariate analyses. On multivariate analysis, HER2/neu over expression and Ki-67 -20% were independent predictive factors of brain relapse (Odds Ratio (OR) 2.55, 95% confidence intervals (CI) 1.10-5.94 and OR 2.97, 95% CI 1.01-8.73, respectively). Endocrine unresponsive tumours (both ER and PgR <10%) showed an increased risk of relapse with BM of borderline significance (OR 1.91, 95% CI 0.87-4.12).

CONCLUSION

Patients with ER and PgR negative tumours either with or without HER-2/neu over expression should be considered at higher risk of BM.

Understanding the choice of participating in clinical trials

9091

Background: The choice of whether to participate in a clinical trial by patients (pts) with cancer can be influenced, beyond trial information, by patient's own emotional and cultural properties, including past history as well as prejudices. Our hypothesis was that a better knowledge of these cultural and emotional features might be useful to improve patients-doctor dialogue, leading patients to a more conscious motivation to make the choice. Methods: We developed a 17-items, multiple-choice and open-answer questionnaire, to capture motivations for participating, or declining to take part, in clinical trials. Further information included family relationships, schooling and clinical symptoms. Patients were required to have advanced lung or breast cancer and to have never discussed participation in a clinical trial. Results: The questionnaire was answered by all the 42 pts who received it. Eighty-three percent of pts were positive about their participation. Trust in the investigator (43%) or in the Institute (21%) and hope to receive a new chance for cure (71%), both for themselves and for others, were a major motivation for a positive answer. Forty-eight percent thought participation in a clinical trial as a sign that no other “standard” treatments are available; 19% were worried of unknown side effects and 76% considered detailed information on expected toxicity to be helpful in making the decision. Sixty percent of patients were afraid of losing “precious time” by participating in a trial; 9% felt exploited as “guinea pigs” and 31% had a some degree of fear that a clinical trial is primarily motivated by economical interests. The most important reasons for accepting an oral experimental drug were its easy use (46%) and having more freedom (36%) Conclusions: Italian patients with advanced breast or lung cancer positively viewed participation in a clinical trial. Several hopes, prejudices and fears have been captured by the questionnaire, which might lead to improve the informed consent documentation and the consciousness of patients in taking their choice. Validation of the findings in a larger cohort of patients will lead to a study on the effect of a specific intervention on informing patients about clinical research.

No significant financial relationships to disclose.

Bisphosphonates and jaw osteonecrosis in patients with advanced breast cancer

BACKGROUND

In recent years, several cases of mandibular necrosis associated with long-term use of bisphosphonates have been reported. The estimated incidence varies from 1% to 4.6%.

PATIENTS AND METHODS

We conducted an observational study with the aim of determining the incidence of jaw osteonecrosis in advanced breast cancer patients with bone metastases under bisphosphonate treatment and to identify subjects at higher risk of developing this complication evaluating preclinical signs. We considered two groups of patients. All the patients complaining of odontostomatological symptoms underwent maxillary CT scan and maxillo-surgeon clinical examination. Asymptomatic patients were asked to perform a standard orthopantomography (OPT).

RESULTS

From February 2005 to October 2005, we observed five patients with jaw bone necrosis (6%). Diagnosis was radiological and clinical. In two patients a confirmatory biopsy was performed. In the same time interval, OPTs were collected from 76 asymptomatic patients. Three OPTs revealed radiological features of suspicious mandibular necrosis. Maxillary CT scan confirmed the presence of an osteolityc area with signs of periosteal reaction. All the three patients were referred to maxillo-surgeon and two out of three patients underwent mandibular biopsy, but histopathological results were not conclusive.

CONCLUSIONS

In our experience, the incidence of jaw bone necrosis in breast cancer patients seems to be higher than in other reports (6%). Radiological features of suspicious jaw necrosis were observed in three asymptomatic patients. We do not know how these findings should be considered. Anyway, standard OPT is a simple procedure, and may allow identification of periodontal conditions that in some way can predispose to the development of this uncommon event.

Pegylated liposomal doxorubicin (PLA) at a metronomic schedule for patients with advanced breast cancer (ABC)

10571

Background: The anti-angiogenic efficacy of chemotherapy (CT) is probably best obtained by administration of low doses of cytotoxics on a frequent or continuous schedule. The aim of this pilot study was to assess feasibility, clinical efficacy and tolerability of PLA, using a “metronomic” schedule in ABC. This schedule has been previously tested in the treatment of Kaposi sarcoma. Methods: From January to November 2005, 36 pts with ABC were treated with PLA, at a dose 20 mg/m2 q14. Almost all the pts were heavily pretreated for ABC and 44% of them received previous anthracycline therapy in adjuvant or metastatic setting. Results: Thirty-four pts were evaluable for toxicity and 29 for response. One pt (3%) had CR, 3 (11%) PR, 12 (41%) NC and 13 (45%) PD, for an overall clinical benefit of 28%. Median response duration was 2.59 mos; median TTP was 3.38 mos (95% CI 2.11–4.64). Treatment was well tolerated with neither G3-G4 NCI-CTC hematological toxicity. Only one pt experienced G3 palmar-plantar erythrodysesthesia (PPE). PPE was observed in other 15 pts (39%), with G2 occurring in 7 (21%). Other common G2 non-hematological toxicities were mucositis in 3 pts (9%) and constipation in 3 pts (9%) Dose reduction, due to subjective or hematological toxicity, was required in 10 pts (36%). No decrease in LVEF > 10% from baseline was observed. Conclusions: Metronomic PLA schedule in pretreated ABC pts seems to be an active and well-tolerated regimen. As to dose-dense CT, targets of metronomic CT might be, in addition to malignant cells, also endothelial and other stromal cells of the progressing metastasis, leading ultimately to the stability and eventually regression of the neoplastic lesion. The lower toxicity profile of the metronomic schedules make their use in pts with ABC very attractive and their testing in the adjuvant setting extremely challenging.

No significant financial relationships to disclose.

Dose-finding and pharmacokinetic study of an all-oral combination regimen of oral vinorelbine and capecitabine for patients with metastatic breast cancer

PURPOSE

A phase I study was performed to determine the maximal tolerated dose, recommended doses (RDs), safety and efficacy of oral vinorelbine when combined with capecitabine in an all-oral chemotherapy regimen in patients with metastatic breast cancer (MBC), with pharmacokinetic blood sampling to investigate potential drug-drug interactions.

PATIENTS AND METHODS

Forty-four patients with MBC received as first- or second-line chemotherapy, oral vinorelbine at a dose of 60 or 80 mg/m2 on days 1 and 8 (and 15) with escalating doses of capecitabine from 1650 to 2500 mg/m2/day days 1-14 every 3 or 4 weeks. Three schedules were tested: day 1, day 8 and weekly regimens of oral vinorelbine with a 14-day course of capecitabine every 3 weeks; and a days 1 and 8 regimen of oral vinorelbine with a 14-day course of capecitabine every 4 weeks.

RESULTS

With oral vinorelbine at 60 mg/m2, the RDs were established as oral vinorelbine 60 mg/m2 on days 1 and 8 plus capecitabine 2250 mg/m2/day days 1-14 and oral vinorelbine 60 mg/m2/week plus capecitabine 2000 mg/m2/day days 1-14. With oral vinorelbine at 80 mg/m2, the RD was oral vinorelbine 80 mg/m2 on days 1 and 8 plus capecitabine 2000 mg/m2/day days 1-14. Neutropenia was the main dose-limiting toxicity of the combination; it was reported in 40 patients (90.9%), with grade 3 in 14 patients (31.8%) and 6.2% of cycles, and grade 4 in 12 patients (27.3%) and 4.3% of cycles. Complications were rare with only three patients experiencing febrile neutropenia (one episode each). The most frequent non-haematological toxicity was gastrointestinal; however, the incidence of grade 3 was low, with no episode of grade 4. Hand-foot syndrome was reported in 14 patients (31.8%) and 22.6% of cycles, with grade 2 in two patients (4.5%) and 1.2% of cycles (two episodes each). No episode of grade 3 was observed. Objective responses were reported in 18 patients (three complete responses and 15 partial responses), yielding a response rate of 40.9% in the intention-to-treat population according to the investigator assessment. Results from the pharmacokinetic study demonstrated the absence of mutual pharmacokinetic interactions when both drugs were co-administered.

CONCLUSIONS

The combination of oral vinorelbine and capecitabine is safe and easy to administer in an outpatient setting. This all-oral combination chemotherapy may offer a good alternative to the intravenous route for patients with MBC. Based on these promising results, a phase II study has started using oral vinorelbine 60 mg/m2/week with capecitabine 2000 mg/m2/day days 1-14 every 3 weeks as first-line chemotherapy in patients with MBC.

Self-image of adolescent survivors of long-term childhood leukemia

The purpose of our research was to evaluate the attitude to face the life cycle and the impact that the experience of childhood leukemia may have had in a group of adolescents who had the disease cured. A questionnaire was administered at the Pediatric Hematology Center, San Gerardo Hospital, Monza, Italy, to all former patients age 12 to 20 years and off therapy from leukemia for at least 2 years (total of 116 adolescents) during 1997; 70 patients responded to the mailing and a comparison group of 70 secondary-school students was investigated. The two groups were matched as closely as possible on key characteristics (age, gender, socio-economic level of families, education and occupation of the parents, and geographic area of residence). The Offer Self-Image Questionnaire was the instrument used in this study. Overall, the teenagers in whom leukemia was cured showed a more positive and mature self-image (psychologic, social, attitude toward family, and coping) compared with the student group (statistical evidence, P < 0.05). An effective psychosocial support for patients and their families during their treatment, in addition to medical therapy, is strongly recommended. The majority of survivors of childhood cancer grow successfully without serious psychologic sequelae.

School functioning for the child with leukemia in continuous first remission: screening high-risk children

It is well known in the literature that cancer creates educationally related barriers for all children, which may or may not contribute to clinically relevant school problems. The goal of this study was to obtain a base rate for the characteristic pattern of school functioning for children with leukemia, so that the children with the most serious difficulties might be discovered and given the different and flexible help needed. From 1988 through 1994, a questionnaire was administered annually to teachers of all leukemic children in our center. The 291 questionnaire were used to compare the school functioning of children with leukemia with that of matched controls chosen by each teacher as representative of the class as a whole, excluding special education and developmentally disabled students. This approach to matching was chosen as a control for socioeconomic factors as well. The study was conducted with all patients with leukemia entering the center residing in the region of Lombardy, attending school, and either in therapy or out of therapy. After initial treatment, the children with leukemia in our center as a group attended school regularly and willingly. Analyses of variance (ANOVAs) were conducted on the total scores and on scores for each of the subareas of learning, socialization, and emotionality. T-tests, were given to contrast individual item scores of patients with those of their matched controls. On most individual items, children with leukemia did not differ from their classmates. However, significant discrepancies between children with leukemia and their classmates appeared consistently year after year on overall total scores and on each of the three major subcomponents of the test (learning, socialization, and emotionality). The groups most affected were children who were cranially irradiated and children who were under 6 years of age at diagnosis. Children who have been irradiated and children diagnosed under 6 years of age have the greatest risk for difficulties in school functioning and are candidates for greater attention and preventive efforts.

Number and distribution of melanocytic nevi in individuals with a history of childhood leukemia

BACKGROUND

An increased number of melanocytic nevi at the termination of chemotherapy has been documented in children with hematologic malignancies. The persistence of the increased number of nevi over time and the relationship with personal (e.g. phenotype) and disease related variables remain to be explored.

METHODS

One hundred Italian patients diagnosed as having acute lymphatic or myeloid leukemia, after 1975, were recruited and compared with a group of 100 control individuals drawn from friend of the enrolled patients. Information regarding lifetime sun exposure, phenotypic characteristics, and number of nevi was collected by experienced dermatologists. Counts of nevi were expressed both as totals and as counts per unit of body surface area ("density"). Multiple linear regression analysis was employed to control for potentially confounding factors when comparing patients and controls.

RESULTS

The patients and controls were fairly comparable in terms of constitutional characteristics, but the patients had a significantly higher number and density of nevi > or = 2 mm or larger in diameter. In addition, patients had a greater number of large nevi ( > or = 6 mm in greatest dimension), and of nevi in unusual areas, such as the palms and soles. Differences in nevus density between patients and controls were notably maintained in the older age group ( > 12 years). None of the disease-related factors analyzed (e.g. treatment protocol and radiotherapy), appeared to be significantly correlated with nevus density.

CONCLUSIONS

Patients with a history of childhood leukemia have a sustained increase in their nevus density. A fairly convincing body of evidence indicates that a large number of melanocytic nevi is the strongest risk factor for melanoma. Therefore, the utility of periodic skin examination of these should be considered.

[Evaluation of family satisfaction in pediatric oncology]

The satisfaction for the care receveid following the diagnosis of acute linfoblastic leukemia in the Pediatric Division of the San Gerardo Hospital of Monza was explored with a questionnaire to the families of patients diagnosed from January 1984. 217 questionnaires were returned (59.2%); 67% were completed by both parents. Parents expressed overall a very high satisfaction for several areas of care: 93.8% for the information about diagnosis; 83% approved the use of the word "leukemia". Judgements on technical competence and communication skills of the health care professionals were analyzed separately for hospitalized and day-hospital patients, and for survivors and dead: results were highly positive for both groups. The expected higher of missing data for the questions related to satisfaction for communication on relapses, highlights the difficulty and the emotional load of the question. Data were discussed by the health care team as well as parents in order to obtain a feedback and practical suggestions for further improvement of care.

Bone marrow transplantation for childhood leukemia: five years' experience in a pediatric hematology center

BACKGROUND

Fifty-three children (39 male, 14 female, median age 9 years 3 months) with different forms of leukemia underwent bone marrow transplantation (BMT) at our center. Various conditioning regimens were used according to the disease and time of BMT. In this paper we evaluate the impact of the experience of a pediatric hematology center on BMT-related problems in children.

METHODS

We analyzed disease-free survival (DFS), early BMT-related effects, hepatic, cardiac and respiratory function and late endocrine effects as shown by standard instrumental and laboratory tests.

RESULTS AND CONCLUSIONS

Outcome (overall median follow-up 34 months) was satisfactory. Three years DFS was 50.1% in all patients, 58.8% in lymphoblastic leukemia in 2nd complete remission (CR), and 50.0% in acute myeloid leukemia (some in 2nd or subsequent CR). Three of four patients with chronic myeloid leukemia were alive at 38 months. Management of the problems causing early post-BMT toxicity contributed to a progressive fall in early morbidity and mortality (14.3% in the last 3 years). Pre-BMT hepatitis in most patients was not associated with increased post-BMT hepatotoxicity. Cardiac function, even in patients given aggressive anthracycline treatment before BMT, remained normal 3 years after transplantation, as did respiratory function, although 8 cases presented subclinical restrictive and/or obstructive alterations. Compensated hypothyroidism was observed in 9 patients. Six boys received replacement treatment for hypogonadism. Severe height impairment was seen in 2 patients. Post-BMT endocrine and growth effects require a longer follow-up for definitive conclusions to be drawn.(ABSTRACT TRUNCATED AT 250 WORDS)

[DMFT index values in patients treated for leukemia during growth]

Patients affected by acute leukemia under radiotherapy and chemotherapy, less than 12 years old were investigated about DMFT index. Patients were in total remission. All erupted permanent teeth, with attention to an eventual oligodontia of non erupted teeth also, excluding third molars, were investigated by clinical and X-Ray examination. Authors concluded that there is no difference between these patients and normal subjects for this index.

Treatment of isolated testicular relapse in childhood acute lymphoblastic leukemia: an Italian multicenter study. Associazione Italiana Ematologia ed Oncologia Pediatrica

Between May 1980 and April 1987, 49 children with acute lymphoblastic leukemia (ALL) in isolated testicular and first leukemia relapse (ITR) were enrolled in the Associazione Italiana Ematologia ed Oncologia Pediatrica (AIEOP) multicenter study REC80-ITR. According to the Rome Workshop criteria, 77% were at standard and 23% at high initial prognostic risk. In 33% of the cases, ITR occurred during first treatment. The REC80-ITR protocol consisted of an induction phase regimen of vincristine (VCR), cytarabine (ARA-C), methotrexate (MTX), and asparaginase (L-asp), and bilateral testicular irradiation, and CNS prophylaxis with intrathecal MTX and a maintenance phase with a multidrug rotating regimen. Total treatment duration was 30 months. The median time of observation after ITR was 51 months. The Kaplan-Meier estimates of survival and disease-free survival (DFS) at 4 years were 67.7% and 41%, respectively. Patients who had an ITR on therapy or within the first off-therapy year showed the poorest outcome. The DFS at 3 years was 20%, 47.6%, and 100%, respectively, for children who had an ITR on treatment (n = 16), within the first year of treatment withdrawal (n = 22), or later (n = 10) (P = .001). Patients with an asymptomatic occult testicular infiltrate at treatment discontinuation had a very unfavorable prognosis. Eighty-one percent of second relapses involved the bone marrow. In our experience, children presenting an early ITR (ie, within 6 months of treatment withdrawal) need a very aggressive treatment because of the high probability of an underlying systemic disease. On the other hand, patients with a late ITR seem to have a truly local recurrence and can apparently be cured by standard protocols, as shown in protocol REC80-ITR.

Meetings with parents after the death of their child from leukemia

There is a growing interest in the emotional status of parents and siblings after the death of a child with chronic disease. For the past 7 years physicians at our center have systematically contacted parents who lost a child because of leukemia within the first few months after the death. From this experience it appears that most parents needed to talk at least once with the physicians who took care of their child. As expected, some parents and siblings were found to have significant psychological problems and to need psychologic support. We suggest that the opportunity to talk with a physician of the attending staff should be provided routinely to parents shortly after the death of a child from leukemia.

[Leukemia in childhood]

The prognosis of leukemia in children has changed remarkably in the last 20 years. Today more than 50% of children with Acute Lymphoblastic Leukemia (ALL) and about 30% of children with Acute non Lymphoblastic Leukemia (ANLL) can be cured with chemotherapy. The German Group BFM has obtained a significant improvement of results, both in ALL and ANLL using multidrug intensive treatment schedules. In Italy, thanks to the Italian Pediatrics Association of Hematology and Oncology (AIEOP), results have been improved in the last 10 years; very recently, new protocols with the BFM strategy have been started. Allogenic matched bone marrow transplantation (BMT) is indicated in children with ALL in 2nd complete remission (CR) following a relapse during or shortly after discontinuing treatment and in patients with Chronic Myeloid Leukemia. Chemotherapy results remain very poor in these patients. Allogenic BMT in usually performed also in children with ANLL in 1st CR. Autologous BMT, and allogenic BMT mismatched or from unrelated donors are being used with promising results when matched donors are not available. Most children cured of leukemia can enjoy a normal quality of life. However long term studies are still needed to determine the incidence of late effects, and to evaluate the psychosocial impact of the disease. In this context is becoming more and more important the role of the family doctor.

Correlation of gonadal function with histology of testicular biopsies at treatment discontinuation in childhood acute leukemia

Testicular open-wedge biopsy was performed in 35 children in complete remission from acute lymphoblastic leukemia without clinical signs of leukemic testicular infiltration at the time of treatment discontinuation. Histological investigation showed thickening of the tunica propria of the seminiferous tubules in 13 of 35 patients. In 5 of 35 patients, the tubular fertility index was markedly reduced; in 5 of 6 pubertal patients, decreased spermatogenesis or aplasia of germinal epithelium was observed. Histologic damage was found mainly in the germinal cells both in patients treated with cytosine arabinoside and cyclophosphamide and in those treated with antiblastic drugs not considered damaging to the gonads. The extent of impairment was independent of age at start of treatment. On the other hand, endocrinological investigation carried out at the crucial moment of treatment suspension showed normal hypothalamic-hypophyseal-gonadal function as well as normal anthropometric data, bone age, and pubertal stage in the majority of patients. Testicular leukemia was found in only one patient (2.8%) whereas three children with negative testicular biopsies had testicular relapses within 7 months. Therefore, in view of the limits of light microscopy in diagnosing leukemic infiltration at treatment discontinuation, we propose the use of more sophisticated techniques, possibly within 6 months of suspension of therapy.