Cisplatin plus paclitaxel and bevacizumab versus carboplatin plus paclitaxel and bevacizumab for the first-line treatment of metastatic or recurrent cervical cancer

OBJECTIVE

Cisplatin-paclitaxel and bevacizumab is a frequently used treatment regimen for metastatic or recurrent cervical cancer, and carboplatin-paclitaxel and bevacizumab are also among the recommended regimens. In this study we aimed to evaluate the efficacy of these two regimens for the treatment of metastatic or recurrent cervical cancer.

METHODS

Patients with metastatic or recurrent cervical cancer treated with cisplatin-paclitaxel and bevacizumab or carboplatin-paclitaxel and bevacizumab were retrospectively evaluated in this study. The clinical and demographic characteristics of patients in each group were evaluated. Median overall survival, progression-free survival, and response rates between the two groups were compared.

RESULTS

A total of 250 patients were included. Overall, the numbers of patients with recurrent disease and metastatic disease were 159 and 91, respectively. The most common histologic subtype was squamous cell carcinoma (83.2%). The median duration of follow-up was 13.6 (range 0.5-86) months. The median progression-free survival was 10.5 (95% CI 9.0 to 11.8) months in the cisplatin-paclitaxel and bevacizumab group (group 1), and 10.8 (95% CI 8.6 to 13.0) months in the carboplatin-paclitaxel and bevacizumab group (group 2) (HR 1.20; 95% CI 0.88 to 1.63; p=0.25). The median overall survival was 19.1 (95% CI 13.0 to 25.1) months in group 1 and 18.3 (95% CI 15.3 to 21.3) months in group 2 (HR 1.28; 95% CI 0.91 to 1.80; p=0.15).

CONCLUSIONS

There is no survival difference between cisplatin or carboplatin combined with paclitaxel and bevacizumab in metastatic or recurrent cervical cancer.

Hyperprogression after immunotherapy: A comprehensive review

Immune checkpoint inhibitors have revolutionized cancer treatment with patient improved survival, quality of life, and a longer response. However, up to 30% of patients experience paradoxical accelerated tumor progression early after immune-checkpoint blockade therapy. This phenomenon is also known as hyperprogression (HP). Unlike other responses, such as pseudoprogression or natural progression, HP causes worse survival outcomes in patients. Older age, higher metastatic burden, and previous radiation have been independently associated with HP. Even though the exact molecular mechanism underlying HP after immune-checkpoint blockade therapy remains unknown, oncogenic signaling activation including MDM2 amplification or EGFR alterations, the modification of tumor microenvironment by radiotherapy with immune checkpoint inhibitors, and alterations in immune landscape of tumors have been hypothesized as the biological mechanisms behind HP. Patients with HP have been presented with poor prognosis and increased deleterious mutations in cancer genes, along with alterations in the tumor microenvironment. As immune checkpoint inhibitors have been more widely accepted by oncologists, proper assessment of this unique tumor response remains challenging in clinical practice. This work documents the recent findings on epidemiology, biological and clinicopathological factors of HP after immunotherapy.

Different Clinical Features of Primary and Secondary Tumors in Patients with Multiple Malignancies

Clinical features of the first and second primaries in patients with multiple malignancies have not been extensively studied. We compared patient and treatment characteristics of the primary malignancy in 48 consequent multiple primary cancer patients with those of the second primary in the same cohort. The second primaries comprised fewer breast cancers; 29.2% of primaries as opposed to 10.4% of second tumors were breast cancer (P = 0.049). In addition, primary tumors tended to be at a lower TNM stage than secondary tumors (P = 0.060). The median overall survival after the diagnosis of the first primary for the whole cohort was 22.3 years (95% CI, 2.0–42.5) and the median time to presentation of the second malignancy was 38 months after the diagnosis of the first primary (range, 0 to 384). Therefore, the prognosis of cancers in the multiple malignancy group appears to be good and they appear to have an indolent clinical behavior. Thus, we recommend a long screening time for secondary tumors after a curative treatment in patients with common cancers, taking into account the different occurrence patterns of second primaries with respect to first primaries.

The Value of CEA and CA 19-9 in Detecting Cancer in a Group of High-Risk Subjects with Gastrointestinal Symptoms

The aim of this study was to evaluate the clinical value of CEA and CA 19-9 in a potential high-risk population of subjects with gastrointestinal complaints. The basic question was whether the determination of these markers, in addition to some other clinical features in this high risk population, could be helpful in diagnosing intraabdominal cancer. Two hundred and two patients with gastrointestinal complaints underwent standard diagnostic procedures and were followed for at least one year. For every patient, CEA and CA 19-9 levels were obtained at the first examination; the evaluating physician was blinded to the marker levels. The determinants of the likelihood of cancer were evaluated by multivariate analysis. Seventeen patients were diagnosed as having intraabdominal cancers. With the presence of melena (RR=101.63, p=0.007), nonspecific gastrointestinal symptoms (RR=12.54, p=0.026), increasing age (RR=1.09, p=0.028) and abnormal CEA (RR=240.79, p=0.000), the risk of having cancer increased significantly and independently. The presence of a primary gastric complaint was associated with a lower risk of cancer in this cohort (RR=0.01, p=0.04). Markers were not used in the diagnostic workup. In conclusion, in patients presenting with gastrointestinal complaints, the finding of elevated CEA levels may help in the diagnosis of cancer by prompting a more extensive search for intraabdominal cancer.

Retrospective analysis of third-line chemotherapy in advanced non-small cell lung cancer

BACKGROUND

First- and second-line chemotherapies have been demonstrated to be effective in treatment of patients with inoperable, advanced non-small cell lung cancer (NSCLC), although the role of third-line chemotherapy remains unclear. The present investigation assessed treatment outcomes in patients with advanced NSCLC who received third-line and higher chemotherapy.

PATIENTS AND METHODS

This retrospective study included consecutive patients with advanced NSCLC who received at least three lines of systemic chemotherapy.

RESULTS

A total of 72 patients who had received third-line or higher chemotherapy were included in the analysis. The median age of patients was 49 years (range 41-76), and there were 13 (18.1%) women and 59 (81.9%) men. Estimated median survival was 26 months. Moreover, overall survival was significantly longer in patients for whom disease control was achieved after second-line chemotherapy compared to those with disease progression (34 vs. 17 months, respectively). Survival after third-line treatment was significantly longer in the group with Eastern Cooperative Oncology Group (ECOG) performance status 0-1 at the beginning of third-line therapy compared to patients with a status of 2-3.

CONCLUSIONS

In patients with advanced stage NSCLC, administration of third-line and higher systemic chemotherapy may be associated with increase in overall survival. Furthermore, greater increases in overall survival were also observed in patients for whom disease control was achieved after second-line therapy and in those with ECOG performance status of 0-1 before third-line treatment.

Line of abiraterone acetate in castration-resistant metastatic prostate cancer--Does it matter? report of a multi-institutional experience

OBJECTIVE

We present our data comparing retrospectively the efficacy of abiraterone and cabazitaxel in patients who progress after docetaxel treatment.

PATIENTS AND METHODS

The study included 56 patients diagnosed with hormone-refractory metastatic prostate cancer who were previously treated with abiraterone therapy at four oncology centers in Turkey.

RESULTS

With abiraterone, the patients had a median progression-free survival (PFS) of 5.9 months (95% confidence interval (CI) for hazard ratio (HR) (4.4-7.4)) and an overall survival of 13.4 months (95% CI for HR (5.5-21.3)). When we compared the disease-free survival (DFS) of reference patients treated with cabazitaxel as a second-line treatment with those receiving second-line abiraterone therapy, there was no significant difference. (PFS = 5.9 months with cabazitaxel vs. 6.7 months with abiraterone, P = 0.213).

CONCLUSION

This study has shown that in our experience abiraterone acetate is an effective agent in metastatic castration-resistant prostate cancer (mCRPC) regardless of the line of treatment.

Ginseng and cancer

Derived from the Greek word Panacea that means 'cure for all', Ginseng (Panax) has had an important place in Chinese Medicine for many of years. As the name suggests, it is believed to be a miraculous plant effective in the treatment of many health problems. It is claimed to have many effects such as sedative, hypnotic, aphrodisiac, antidepressant, diuretic, and stimulating effects, and to be effective in the treatment of certain health problems such as diabetes, Alzheimer's disease, erectile dysfunction and infections. In addition, its effects on the prevention and treatment of cancer as well as on the reduction of cancer-related symptoms have been prioritized in recent years. However, the studies that have been done so far do not confirm these effects. Although certain favorable results have been obtained in some studies intended for investigating its effects on acute nasopharyngitis, diabetes, Alzheimer's disease, and erectile dysfunction, it is early to say anything conclusive. And in cancer patients, it has been shown to be effective in reducing weakness due to cancer and its treatment. On the other hand, ginseng may cause important drug interactions, although it is described as a relatively safe product. For now, it seems to be reasonable to use ginseng only for cancer-related weakness in cancer patients at this point. But this should definitely be done within the knowledge and under the control of oncologists.

Ganoderma Lucidum (Reishi Mushroom) and cancer

Having a long historical past in traditional Chinese medicine, Ganoderma Lucidum (G. Lucidum) is a type of mushroom believed to extend life and promote health. Due to the increasing consumption pattern, it has been cultivated and marketed intensively since the 1970s. It is claimed to be effective in the prevention and treatment of many diseases, and in addition, it exerts anticancer properties. Almost all the data on the benefits of G. Lucidum are based on laboratory and preclinical studies. The few clinical studies conducted are questionable. Nevertheless, when the findings obtained from laboratory studies are considered, it turns that G. Lucidum is likely to have some benefits for cancer patients. What is important at this point is to determine the components that will provide these benefits, and use them in drug development, after testing their reliability. In conclusion, it would be the right approach to abstain from using and incentivizing this product, until its benefits and harms are set out clearly, by considering its potential side effects.

Impact of Oncotype DX Recurrence Score on Treatment Decisions: Results of a Prospective Multicenter Study in Turkey

INTRODUCTION

Breast cancer is the most common malignancy among Turkish women and the rate of early stage disease is increasing. The Oncotype DX(®) 21-gene assay is predictive of distant recurrence in ER-positive, HER2-negative early breast cancer. We aimed to evaluate the impact of the Recurrence Score(®) (RS) on treatment decisions and physician perceptions in Turkey. We also studied correlations between RS and routine risk factors.

PATIENTS AND METHODS

Ten academic centers across Turkey participated in this prospective trial. Consecutive breast cancer patients with pT1-3, pN0-N1mic, ER-positive, and HER2-negative tumors were identified at multidisciplinary tumor conferences. The initial treatment decision was recorded before tumor blocks were sent to the central laboratory. Each case was brought back to tumor conference after receiving the RS result. Both pre- and post-RS treatment decisions and physician perceptions were recorded on questionnaire forms. Correlations between RS and classical risk factors were evaluated using univariate and multivariate analyses.

RESULTS

Ten centers enrolled a total of 165 patients. The median tumor size was 2 cm. Of 165 patients, 57% had low RS, 35% had intermediate RS, and 8% had high RS, respectively. The overall rate of change in treatment decision was 33%. Initially, chemotherapy followed by hormonal therapy (CT+HT) was recommended to 92 (56%) of all patients, which decreased to 61 (37%) patients post-RS assay (p<0.001). Multivariate analysis indicated that progesterone receptor (PR) and Ki-67 scores were significantly related to RS.

CONCLUSION

Oncotype DX testing may provide meaningful additional information in carefully selected patients.

Dietary and demographical risk factors for oesophageal squamous cell carcinoma in the Eastern Anatolian region of Turkey where upper gastrointestinal cancers are endemic

BACKGROUND

Oesophageal squamous cell carcinoma (ESCC) is endemic in the Eastern Anatolian region of Turkey. The present study was performed to identify risk factors for ESCC that specifically reflect the demography and nutritional habits of individuals living in this region.

MATERIALS AND METHODS

The following parameters were compared in 208 ESCC patients and 200 control individuals in the Eastern Anatolian region: age, sex, place of living, socioeconomic level, education level, smoking, alcohol intake, nutritional habits, and food preservation methods.

RESULTS

The mean age of ESCC patients was 56.2 years, and 87 (41.8%) were 65 years-old or older. The ratio of women to men in the patient group was 1.39/1. ESCC patients consumed significantly less fruit and yellow or green vegetables and more hot black tea, 'boiled yellow butter', and mouldy cheese than did control individuals. Residence in rural areas, smoking, and cooking food by burning animal manure were also significantly associated with ESCC.

CONCLUSIONS

The consumption of boiled yellow butter and mouldy cheese, which are specific to the Eastern Anatolian region, and the use of animal manure for food preparation were identified as risk factors in this region. Further studies are required to potentially identify the carcinogenic substances that promote the development of ESCC in this region.

Curcumin (Turmeric) and cancer

Curcumin is a substance obtained from the root of the turmeric plant, which has the feature of being a yellow or orange pigment. It is also the main component of curry powder commonly used in Asian cuisine. Curcumin, a substance that has had an important place in traditional Indian and Chinese medicines for thousands of years, has been the center of interest for scientific studies especially in the field of cancer treatment for several years. Laboratory studies have presented some favorable results in terms of curcumin's antioxidant, antiinflammatory and anticancer properties in particular. However, since such findings have yet to be confirmed in clinical studies, its effect on humans is not clearly known. Therefore, when its advantages in terms of toxicity, cost and availability as well as the favorable results achieved in laboratory studies are considered, it would not be wrong to say that curcumin is a substance worth being studied. However, for now the most correct approach is to abstain from its use for medical purposes due to lack of adequate reliable evidence obtained from clinical studies, and because of its potential to interfere with other drugs.

Use of blood transfusion at the end of life: does it have any effects on survival of cancer patients?

BACKGROUND

Treatment of anemia is an important issue in the palliative care setting. Blood transfusion is generally used for this purpose in supportive care. However the place of blood transfusion in terminally ill cancer cases is less far established.

OBJECTIVE

We aimed to outline the use of transfusions and to find the impact of blood transfusion on survival in patients with advanced cancer and very near to death.

DESIGN

Patients dying in 2010-2011 with advanced cancer were included in the study. We retrospectively collected the data including age, type of cancer, the duration of last hospitalisation, ECOG performance status, Hb levels, transfusion history of erythrocytes and platelets, cause and the amount of transfusion. The anaemic patients who had transfusion at admission were compared with the group who were not transfused. Survival was defined as the time between the admission of last hospitalisation period and death.

RESULTS

Three hundred and ninety eight people with solid tumours died in 2010-2011 in our clinic. Ninety percent of the patients had anemia at the time of last hospitalisation. One hundred fifty three patients had erythrocyte transfusion at admission during the last hospitalisation period (38.4%). In the anaemic population the duration of last hospitalisation was longer in patients who had erythrocyte transfusion (15 days vs 8 days, p<0.001).

CONCLUSIONS

Patients who had blood transfusion at the end of life lived significantly longer than the anaemic patients who were not transfused. This study remarks that blood transfusions should not be withheld from terminal cancer patients in palliative care.

The West Haven Yale Multidimensional Pain Inventory: Reliability and validity of the Turkish version in individuals with cancer

PURPOSE

Pain is a complex, multidimensional and subjective phenomenon that is common in patients with cancer. The translation of existing pain measurement scales is considered important in producing internationally comparable measures for evidence based practice. In measuring the pain experience, the WHYMPI is a widely used instrument to measure assessment of clinical pain, and it has not been validated in Turkey. The present study aimed to assess the reliability and validity of the Turkish version of the West Haven Yale Multidimensional Pain Inventory (WHYMPI).

METHOD

In this methodological study, the scale was translated into simplified Turkish by the cross-culture translation method, and 520 participants with cancer were assessed. The internal consistency, item analysis, and test-retest methods were used to determine the reliability of the Turkish WHYMPI. Content validity, criterion validity, convergent/divergent validity, and exploratory factor analysis were used to test the construct validity of the Turkish WHYMPI.

RESULTS

Cronbach's alpha and item-total correlations results suggested that there was good internal reliability. The Cronbach's alpha for internal consistency of the pain experience, responses by significant others, and daily activities were 0.85, 0.60, and 0.83, respectively. The internal consistency coefficient for test-retest reliability of the pain experience, responses by significant others, and daily activities were acceptable: 0.82, 0.66, and 0.81, respectively. Factor loadings were significant, with standardised loadings ranging from 0.40 to 0.92.

CONCLUSIONS

WHYMPI is reliable and valid instrument for the measurement of pain in patients with cancer in Turkey. Its use is recommended for clinical and research purposes.

Can positron emission tomography-computed tomography predict response in locally advanced rectal cancer patients treated with induction folinic acid and 5-florouracil?

OBJECTIVE

The aim of this study was to determine the pathological complete response rates in a group of locally advanced rectal cancer patients who underwent chemoradiotherapy (CRT) after treatment with induction folinic acid and 5-florouracil (FOLFOX) chemotherapy and the relationship between the complete response and positron emission tomography-computed tomography (PET-CT).

MATERIALS AND METHODS

The files of 239 patients who were diagnosed with rectal cancer between January 2008 and January 2012 were evaluated retrospectively. Of these, there were 24 locally advanced rectal cancer patients who met the following criteria: They were administered CRT after receiving four courses induction oxaliplatin, FOLFOX and they underwent PET-CT for staging and for the evaluation of their response to FOLFOX treatment. Of these 24 patients, 20 operable patients were included in the study.

RESULTS

The pathological complete response was obtained in seven patients (35%) who were operated on and then given induction four courses FOLFOX chemotherapy and CRT. We determined that age, gender, clinical stage at diagnosis and PET-CT before and after induction chemotherapy were not predictive of the pathological complete response to tumor fluorodeoxyglucose uptake activity.

CONCLUSION

The rates of pathological complete response were increased in locally advanced rectal cancer patients who underwent short-term induction chemotherapy. Although the PET-CT has retained its importance in predicting pathological complete response, there is still a need for studies with a larger number of patients and long-term follow-ups.

Prognostic factors in clinical stage T4N2 locally advanced non-small cell lung cancer

PURPOSE

Relatively few studies have focused on T4N2 (stage IIIB) locally advanced non-small cell lung cancer (NSCLC). In this study, we tried to identify prognostic factors for patients with clinical stage T4N2 NSCLC.

METHODS

We retrospectively identified 223 patients, of which 168 met the inclusion criteria. Patients treated with curative intent using concurrent chemoradiotherapy (CRT) with or without adjuvant chemotherapy, or concurrent CRT after induction chemotherapy, were included in this study. Relevant patient, treatment, and disease factors were evaluated for their prognostic significance in both univariate and multivariate analyses using the Cox proportional hazards model.

RESULTS

The median progression-free survival (PFS) was 13 months (95% confidence interval [CI], 10.6-15.4). The median overall survival (OS) was 20 months (95% CI, 16.8-23.1), and 71, 40.3 and 28.2% of the patients survived for 1, 2 and 3 years after diagnosis, respectively. Multivariate analysis showed Eastern Cooperative Oncology Group (ECOG) performance status (PS) was independent predictor of PFS (hazard ratio [HR], 0.24; 95% CI, 0.13-0.43; p=0.001), and OS [HR, 0.48; 95% CI, 0.26-0.87; p=0.015). Absence of multifocal T4 tumors was also associated with a significantly longer OS (HR, 046; 95% CI, 0.31-0.7; p=0.001). There was no statistically significant difference in OS and PFS between treatment modalities.

CONCLUSION

PFS and OS were significantly shorter in patients with poor ECOG PS. OS was also significantly shorter in patients with multifocal T4 tumors. There were no differences between the two therapeutic approaches with respect to outcome.

Determinants of opioid efficiency in cancer pain: a comprehensive multivariate analysis from a tertiary cancer centre

BACKGROUND

Pain is one of the most terrifying symptoms for cancer patients. Although most patients with cancer pain need opioids, complete relief of pain is hard to achieve. This study investigated the factors influencing persistent pain-free survival (PPFS) and opioid efficiency.

MATERIALS AND METHODS

A prospective study was conducted on 100 patients with cancer pain, hospitalized at the medical oncology clinic of Akdeniz University. Patient records were collected including patient demographics, the disease, treatment characteristics, and details of opioid usage. Pain intensity was measured using a patient self-reported visual analogue scale (VAS). The area under the curve (AUC) reflecting the pain load was calculated from daily VAS tables. PPFS, the primary measure of opioid efficacy, was described as the duration for which a patient reported a greater than or equal to two-point decline in their VAS for pain. Predictors of opioid efficacy were analysed using a multivariate analysis.

RESULTS

In the multivariate analysis, PPFS was associated with the AUC for pain (Exp (B)=0.39 (0.23-0.67), P=0.001), the cumulative opioid dosage used during hospitalisation (Exp (B)=1.00(0.99-1.00), P=0.003) and changes in the opioid dosage (Exp (B)=1.01 (1.00-1.01), P=0.016). The change in VAS score over the standard dosage of opioids was strongly associated with current cancer treatment (chemotherapy vs. others) (β=-0.31, T=-2.81, P=0.007) and the VAS for pain at the time of hospitalisation (β=-0.34, T=-3.07, P= 0.003).

CONCLUSIONS

The pain load, opioid dosage, concurrent usage of chemotherapy and initial pain intensity correlate with the benefit received from opioids in cancer patients.

Use of chemotherapy at the end of life in Turkey

Background

An increasing number of patients receive palliative chemotherapy near the end of life. The aim of this study is to evaluate the aggressiveness of chemotherapy in Turkish individuals near the end of life.

Methods

Patients diagnosed with solid tumors and died from 2010 to 2011 in the medical oncology department of Akdeniz University were included in the study. Data about the diagnosis, treatment details and imaging procedures were collected.

Results

Three hundred and seventy-three people with stage IV solid tumors died from 2010 to 2011 in our clinic. Eighty-nine patients (23.9%) patients underwent chemotherapy in the last month of life while 39 patients (10.5%) received chemotherapy in the last 14 days. The probability of undergoing chemotherapy in the last month of life was influenced by: age, ‘newly diagnosed’ patients, and performance status. There was no significant association of chemotherapy in the last month of life with gender and tumor type. Having a PET-CT scan did not alter the chemotherapy decision.

Conclusion

In conclusion, chemotherapy used in the last month of life in a tertiary care center of Turkey is high. Increasing quality of life should be a priority near the end of life and physicians should consider ceasing chemotherapy and direct the patient to early palliative care.

Oral cyclophosphamide and etoposide in treatment of malignant pleural mesothelioma

BACKGROUND

Malignant mesothelioma (MM) is almost always fatal and few treatment options are available. The aim of this study was to evaluate the efficacy of oral cyclophosphamide and etoposide for patients who underwent standard treatment for advanced MM.

MATERIALS AND METHODS

This study included 22 malignant pleural mesothelioma patients who were treated with oral cyclophosphamide and etoposide (EE).

RESULTS

The average follow-up period of the patients was 39.1 months. Under the treatment of oral EE, median progression- free survival was 7.7 months [95%CI HR (4.3-11.1)] and median overall survival was 28.1 months [95%CI HR (5.8-50.3)]. The treatment response rates were as follows: 4 patients (27.3%) had a partial response (PR), 12 (54.5%) had stable disease (SD), and progressive disease (PD) was observed in 6 (35.9%).

CONCLUSIONS

Oral EE can be administered effectively to patients with inoperable malignant mesothelioma who had previously received standard treatments.

Prolonged progression-free survival with maintenance metronomic oral cyclophosphamide and etoposide treatment in macroscopic residual disease or recurrent/advanced stage ovarian cancer

PURPOSE

In ovarian cancer permanent remission may be provided with optimal cytoreductive surgery and adjuvant chemotherapy. However survival is short in patients with residual macroscopic disease after surgery or recurrent ovarian cancer. Applicable maintenance therapies with low toxicity are required to prolong progression-free survival (PFS) for patients with no curative treatment options. In this study, we investigated the effect of maintenance metronomic oral cyclophosphamide and etoposide (CE) in ovarian cancer patients with post operative residual or recurrent disease.

METHODS

Forty five patients that received metronomic oral CE (cyclophosphamide 50 mg/daily and etoposide 50 mg for 1-5 days, every 21 days) as maintenance therapy for residual disease due to incomplete surgical resection or recurrent advanced-stage ovarian cancer were evaluated. The time between the beginning of oral CE and disease progression was also evaluated.

RESULTS

The mean patient age was 58 years, the vast majority had serous adenocarcinoma (78%) and received a mean of 2 (range 1-4) lines of various intravenous regimens for postoperative residual or recurrent disease. Mean duration of oral CE was 11.3 months (range 2.9-29). Median PFS was 10.3 months (range 7.9-12.8). Only 5 patients discontinued treatment due to intolerance and grade 3-4 toxicity was recorded in 3 patients (7%).

CONCLUSION

Maintenance metronomic oral CE treatment was found effective, minimally toxic and sustainable in patients with macroscopic residual or recurrent advanced-stage ovarian cancer. However, randomized and placebo-controlled well designed studies are required.

Yttrium-90 radioembolization in patients with unresectable liver metastases: determining the factors that lead to treatment efficacy

INTRODUCTION

Locoregional treatments, such as radioembolization, can be used to treat patients with unresectable liver metastases. We aimed to determine the progression-free survival and factors that predict survival of patients with liver metastases whose response to selective internal radiation therapy (SIRT) with Y-90 was assessed by positron emission tomography-computed tomography (PET-CT).

PATIENTS

Our study included 78 liver cancer patients who were treated with Y-90 radioembolization.

RESULTS

The post-treatment response rates were as follows: 7 patients (9%) had stable disease (SD), 26 patients (33.3%) had a partial response (PR), 4 patients (5.1%) had a complete response (CR). The median hepatic progression-free survival (HPFS) was 4.4 months while median overall survival was 10.1 months. Univariate analysis revealed that HPFS is significantly affected by international normalized ratio (INR) levels and age (Hazard Ratio(HR)=0.54 (95%CI:0.30-096), P=0.034, HR=1.03(95%CI:1.00-1.05), P=0.051). However, only INR levels retained significance with multivariate analysis (HR=0.53 (95%CI:0.30-0.93), P=0.028), while age had limited significance (HR =1.02 (95% CI:1.00-1.05), P=0.051).

CONCLUSIONS

We determined that Y-90 radioembolization is effective as a salvage therapy in patients with predominant liver metastases. For the first time, we showed that age and INR values reflecting the functional hepatic reserve can be used as positive predictive factors for HPFS.

Is sunlight a predisposing factor for triple negative breast cancer in Turkey?

INTRADUCTION: There is known to be a relationship between vitamin D level and more aggresive breast cancer subtypes, especially triple-negative breast cancer (TNBC). It was reported that sunlight exposure has an effect on the prognosis of patients with cancer, possibly related to the conversion of vitamin D to its active form with sunlight. We aimed to evaluate the effect of sunlight exposure on patients with TNBC.

MATERIALS-METHODS

A total of 1,167 patients with breast cancer from two different regions of Turkey (Antalya and Kayseri, regions having different climate and sunlight exposure intensity over the year) were analysed retrospectively. The ratio of patients with TNBC was identified in those two regions.

RESULTS

The ratio of patients with TNBC was 8% and 12% for Kayseri and Antalya regions, respectively, and this difference between the two groups was statistically significant (p=0.021).

DISCUSSION

Sunlight exposure may be associated with more prevalent TNBC. This finding should be investigated with a prospective study.

Basal proteinuria as a prognostic factor in patients with metastatic colorectal cancer treated with bevacizumab

BACKGROUND

The beneficial effects of bevacizumab, a widely used agent in metastatic colorectal cancer (mCRC), on clinical survival have been proven. This study investigated the correlation of the clinical benefits and prognosis with proteinuria and other parameters.

METHODS

The study included mCRC patients receiving bevacizumab. Hypertension, 24-hour urine proteinuria, and other routine parameters were recorded at baseline and at certain intervals during treatment.

RESULTS

The study included 36 consecutive patients. The median progression-free survival (PFS) duration was 10.9±2.6months, and the median overall survival (OS) was 23±3.1months. The median PFS was 7.2months among patients with basal proteinuria above 114mg/day, whereas the median PFS was 12months among patients with an equal or lower level (P=0.010). Similarly, PFS was shorter in patients with high lactate dehydrogenase (LDH) or carcinoembryonic antigen (CEA) levels (LDH, P=0.022; CEA, P=0.014). Bevacizumab response's performance status was good (P=0.05) and was even better in patients with a single liver metastasis (P=0.034) or hypertension (P=0.034).

CONCLUSIONS

We demonstrated that high basal proteinuria, LDH, or CEA levels may be negative prognostic factors in mCRC patients receiving bevacizumab.

Complete Response of Primary Bladder Adenocarcinoma with the FOLFOX4 Regimen

Introduction: Primary adenocarcinoma of the bladder is a very rare disease that is difficult to treat. In this paper, we report the second case in the literature with primary mucinous adenocarcinoma of the bladder which showed complete response to FOLFOX4 (fluorouracil, leucovorin, oxaliplatin) chemotherapy regimen. Case Report: A 41-year-old man was admitted to our hospital with a diagnosis of primary adenocarcinoma of the bladder. Due to the similarity in histology with colon carcinoma, a FOLFOX4 regimen was started. Complete response was achieved at the end of this treatment. Today the patient is free of local or systemic disease. Conclusion: FOLFOX4 regimen may be a treatment option for primary adenocarcinoma of the bladder.

The importance of COX-2 expression as prognostic factor in early breast cancer

PURPOSE

A number of studies have been carried out, showing that the risk for breast carcinoma is decreased in those using non-steroidal anti-inflammatory drugs (NSAIDs). Increased cyclooxygenase-2 (COX-2) level is considered as a factor indicating poor prognosis and responsible for angiogenesis, increased cellular proliferation, apoptotic defect and aromatase enzyme induction. For this reason the level of COX-2 might have a prognostic and predictive value in breast cancer as well. This question has become the basis of the present study.

METHODS

Eighty-eight female patients with early stage breast cancer being under adjuvant anthracycline based chemotherapy were prospectively recruited. The patient age, body weight, menopausal status, tumor size and grade as well as axillary lymph node involvement were recorded. Routine pathological examination was performed, and COX-2, CerbB2 (HER2), estrogen (ER) and progesterone receptors (PR) levels in breast cancer tissue were determined immunohistochemically.

RESULTS

Multivariate analysis confirmed the independent predictive value of both menopausal status and ER expression for overall survival (OS) (p=0.009, HR=1.92, and p=0.014, HR=0.20, respectively). A negative correlation was observed between COX-2 levels and the levels of ER and PR (p=0.006, R= -0.303, and p=0.004, R=-0.312, respectively) whereas no significant correlation was observed concerning CerbB2. No statistically significant correlation was determined between COX-2 levels and the disease-free (DFS) and OS rates.

CONCLUSION

Further studies investigating the role of COX- 2 levels in breast cancer progression are needed.

Multicentric ipilimumab experience in Turkish patients with metastatic melanoma: MIPI-TURK at 30 months of follow-up

e20006

Background: Ipilimumab, an anti-CTLA-4 (cytotoxic T lymphocyte-associated antigen) monoclonal antibody has been shown to enhance immune responses and improve overall survival in patients with metastatic melanoma. The authors report retrospectively on metastatic melanoma patients treated under the Expanded Access Program in Turkey among 13 centers. Methods: Patients with metastatic melanoma were treated with ipilimumab 3 mg/kg every 3 week for 4 doses. Response evaluation was done on week 12. Patients with complete response (CR), partial response (PR), and stable disease (SD) at week 12 were eligible for re-treatment. Results: A total of 97 patients enrolled with 77 evaluable. Ipilimumab treatment was given as 2nd (20.0%), 3rd (64.3%), and 4th(15.7%) line. The rate of the patients receiving ipilimumab for 1, 2, 3, and 4 doses were 5.2%, 11.7%, 16.9%, and 62.3%, respectively. Seven of 77 patients were eligible for re-treatment. G1/2, G3/4, and G5 adverse events were reported in 23.4% (18/77), 14.3% (11/77), and 2.6% (2/77) of the patients, respectively. The most common G1/2 immune related adverse events were rash (14.3%), muscle weakness (10.0%), and gastrointestinal side effects (8.6%). There were seven G3 side effects (diarrhea in 4, muscle weakness in 1, hypothyroidism in 1, and GI bleeding in 1 patient) and four G4 side effects (thrombocytopenia in 1, diarrhea in 1, sinus tachycardia in 1, and multiple organ failure in 1 patient). Two deaths (G5) were associated with hepatic AEs. Regarding the response evaluation, there was no CR within 16 months of follow-up period and the median overall progression free survival duration was 2 months (95% CI, 1.6-2.5). The disease control rate was 38.8% (PR: 16.3% and SD: 22.5%). Median time to progression was 2 months (95% CI, 1.8-3.1 months). Of the patients, 31.9%, 22.2%, and 19.2% survived within 12, 24, and 30 months of follow-up period, respectively, and the median overall survival duration was 6 months (95% CI, 3.5-8.5). Conclusions: Ipilimumab treatment resulted in favorable clinical benefit for metastatic melanoma patients. Data generated by 13 centers revealed an efficacy and safety profile consistent with the currently available ipilimumab trials.

Capecitabine plus bevacizumab (Cape-Bev) as a maintenance treatment after induction treatment with FOLFIRI plus bevacizumab (FOLFIRI-Bev) in metastatic colorectal cancer (mCRC)

e14683

Background: Bevacizumab is human monoclonal antibody that inhibits vascular endothelial growth factor and has been shown improvement progression-free survival and overall survival when combined with chemotherapy for treatment of mCRC in the first and second-line settings. The purpose of this study is to show the effectiveness of maintenance therapy with Cape-Bev in patients with mCRC who benefit of first-line (induction) chemotherapy with FOLFIRI-Bev. Methods: The study included patients with mCRC who received FOLFIRI-Bev as first-line chemotherapy. Maintenance therapy with Cape-Bev (Cape 1000 mg/m2 bid d1-14, Bev 7,5 mg/kg d1 q3w) was given until disease progression to patients who had achieved an objective response after 6-months FOLFIRI-Bev regimen. The time to disease progression, survival and toxic effects were analyzed from the beginning of bevacizumab-based chemotherapy. Results: We enrolled 30 patients, 16 men and 14 women. The mean age of the patients was 62 years. The patients who administered maintenance treatment received a median number of 11 cycles. The median progression-free and overall survivals were 22±4 months and 39±4 months, respectively. Significantly higher PFS and OS were seen among patients who complete or near-complete response to induction therapy with FOLFIRI-Bev (Table). Acceptable hand-foot syndrome was observed 14 patients (%51) treated with the Cape-Bev. No patient experienced severe toxicity. Conclusions: Cape-Bev regimen may be an effective maintenance treatment after response to first-line (induction) FOLFIRI plus bevacizumab treatment in selected mCRC with favorable safety profile. Further studies will be needed to demonstrate conclusively that. [Table: see text]

Can PET CT predict response in locally advanced rectal cancer patients treated with induction FOLFOX?

e14696

Background: The aim of this study was to determine the pathological complete response rates in a group of locally advanced rectal cancer patients who underwent chemoradiotherapy after treatment with induction FOLFOX chemotherapy and the relationship between the complete response and Positron emission tomography - computed tomography (PET-CT). Methods: The files of 239 patients who were diagnosed with rectal cancer between January 2008 and January 2012 were evaluated retrospectively. Of these, there were 24 locally advanced rectal cancer patients who met the following criteria: they were administered chemoradiotherapy after receiving four courses induction oxaliplatin, folinic acid and 5-Florouracil (FOLFOX) and they underwent PET-CT for staging and for the evaluation of their response to FOLFOX treatment. Of these 24 patients, 20 operable patients were included in the study. Results: The pathological complete response was obtained in 7 patients (35%) who were operated on, and then given induction four courses FOLFOX chemotherapy and chemoradiotherapy. We determined that age, gender, clinical stage at diagnosis, and PET-CT before and after induction chemotherapy were not predictive of the pathological complete response to tumor fluorodeoxyglucose (FDG) uptake activity. Conclusions: The rates of pathological complete response were increased in locally advanced rectal cancer patients who underwent short-term induction chemotherapy. Although the PET-CT has retained its importance in predicting pathological complete response, there is still a need for studies with a larger number of patients and long-term follow-ups.

Intraarticular hemorrhage due to bevacizumab in a patient with metastatic colorectal cancer: a case report

Introduction

Bevacizumab is a monoclonal antibody against vascular endothelial growth factor. It is widely used in the treatment of metastatic colorectal cancer. It has some specific side effects including severe bleeding, wound healing problems, gastrointestinal perforation, proteinuria and hypertension.

Case presentation

We present the case of a 65-year old Asian man with synovial metastasis of the knee who experienced intraarticular hemorrhage after bevacizumab treatment. He presented with monoarthritis of the left knee.

Conclusion

Bevacizumab-related hemorrhage can cause serious morbidity and unusual sites of hemorrhage may be seen.

Effects and permanency of the training program "communication with cancer patients" on the opinions of students

Learning to develop the doctor-patient relationship is very important in the treatment of patients with cancer. We aim to train our students in the early years of study about this subject with a course on the patient-doctor communication, prepared for third year students. One hundred fifty-four third year students participated in our study during the 2006-2007 academic years. The same questionnaire was given to the students in the 2009-2010 academic year; their sixth year of study. The rate of return for the questionnaire is 88.7%. Based on this study, we have the opinion that the training given in the third year is beneficial; however, the efficacy of the training diminishes with the advancing years, and therefore, the length of this training should be increased in the upper classes and additional hours should be added.

Multicentric ipilimumab experience in Turkish patients with metastatic melanoma: MIPI-TURK

e19024

Background: Ipilimumab, an anti-CTLA-4 (cytotoxic T lymphocyte-associated antigen) monoclonal antibody has been shown to enhance immune responses and induce durable clinical responses in patients with metastatic melanoma. The authors report retrospectively on metastatic melanoma patients treated under Expanded Access Program in Turkey among 13 centers. Methods: Patients with metastatic melanoma were treated with ipilimumab 3 mg/kg for 4 doses on weeks 1, 4, 7, 10 as induction. Response evaluation was done on week 12. Patients with complete response (CR), partial response (PR) and stable disease (SD) at week 12 were eligible for re-induction. Results: A total of 75 patients enrolled with 70 evaluable. Ipilumumab treatment was given as 2nd, 3rd and 4th line in 20.0%, 64.3% and 15.7% of patients respectively. The numbers of patients receiving ipilimumab for 1, 2, 3 and 4 doses were 9, 12, 13 and 36, respectively. Seven of 70 patients were eligible for re-induction. G1/2 adverse events were reported in 32.8% (23/70) of patients whereas G3/4 was 14.3% (10/70). The most common G1/2 immune related adverse event was skin rash (14.3%) followed by muscle weakness (10.0%) and gastrointestinal side effects (8.6%). There were seven G3 side effects (diarrhea in 4, muscle weakness in 1, hypothyroidism in 1 and GI bleeding in 1 patient). There was one reversible G4 thrompocytopenia and two deaths were associated with hepatic AEs. Thirty-six of 70 patients (51.4%) completed 4 doses ipilimumab treatment were available for response evaluation. There was no CR. The disease control rate (DCR) was 36.1% (PR: 8.3% and SD 27.8%). Median time to progression (TTP) was 2.7 months (95% CI, 2.1-4.2 months). Median overall survival was not reached with 61.3% of patients surviving within 12 months of follow up period. Conclusions: As a conclusion, ipilimumab treatment resulted in favorable clinical benefit for metastatic melanoma patients. Data generated by our 13 centers revealed an efficacy and safety profile consistent with the currently avaliable knowledge.

Proteinuria as a predictive factor in metastatic colorectal cancer patients treated with bevacizumab

e14070

Background: Efficacy of bevacizumab -which is widely used at metastatic colorectal cancer (mCRC)- on clinical survival has been proved. But parameters predicting this clinical efficacy are unknown at present. With this study, we aimed to investigate the predictors of treatment benefit with bevacizumab based chemotherapy in patients with mCRC. Methods: Thirty-six successive patients with mCRC receiving bevacizumab based chemotherapy were enrolled into the study. Hypertension, 24-hour proteinuria and other routine parameters were recorded before and during the treatment with certain intervals. After a 1-year follow up, relationship of progression free survival (PFS) and response with various parameters and especially proteinuria, was evaluated. Results: Of 36 patients included, 20 (55.6%) were male and 16 (44.4%) were female, where mean age was 57. Overall median PFS was calculated as 275 days (9.8 months). Patients with basal proteinuria higher than 114 gr/day had a lower median PFS as 184 days (6.5 months) (p=0.046), where median PFS of patients with basal proteinuria equal to or lower than 114 gr/day was not reached. Therefore, higher level of renal proteinuria is a negative prognostic factor in these patients. Similarly, PFS was observed to be lower at patients with high LDH levels (p=0.0024, Exp(B)=23). Bevacizumab response was observed to be better at patients with favorable performance status (p=0.05), who have a single liver metastasis (p=0.034) and who tend to be hypertensive during the treatment (p=0.034). Conclusions: In conclusion, we demonstrated that basal proteinuria and LDH levels may be prognostic at patients with mCRC receiving bevacizumab-based treatment. In the literature, there has been no study up to now that questions basal proteinuria as a prognostic factor for patients receiving bevacizumab-based treatment. This observation is an important step for more focused use of bevacizumab. We believe that it is important to investigate whether basal proteinuria really has a predictive role in this group of patient with further studies, and this has practical and clinical implications.

Coexistence of gastric adenocarcinoma and choriocarcinoma: complete response to trastuzumab and chemotherapy

Gastric choriocarcinoma is a rare neoplasm and usually accompanies gastric adenocarcinoma. The prognosis is poor due to the aggressive course of the disease. A 57-year-old female patient with weight loss and abdominal pain was examined. The patient was operated following the examination, and pathological analysis revealed the presence of a gastric adenocarcinoma associated with choriocarcinoma. Immunohistochemical analysis showed a positive reaction with antibodies to beta-human chorionic gonadotropin and overexpression of the cErbB2 proto-oncogene. Staging revealed multiple metastases in the liver. A complete response was obtained with a combination of trastuzumab and chemotherapy. The diagnosis of gastric choriocarcinomas without pathological examination is difficult due to their rare occurrence. A complete response can be obtained with trastuzumab in the treatment of cases with overexpression of the cErbB2 protein.