Prediction of underlying atrial fibrillation in patients with a cryptogenic stroke: results from the NOR-FIB Study

BACKGROUND

Atrial fibrillation (AF) detection and treatment are key elements to reduce recurrence risk in cryptogenic stroke (CS) with underlying arrhythmia. The purpose of the present study was to assess the predictors of AF in CS and the utility of existing AF-predicting scores in The Nordic Atrial Fibrillation and Stroke (NOR-FIB) Study.

METHOD

The NOR-FIB study was an international prospective observational multicenter study designed to detect and quantify AF in CS and cryptogenic transient ischaemic attack (TIA) patients monitored by the insertable cardiac monitor (ICM), and to identify AF-predicting biomarkers. The utility of the following AF-predicting scores was tested: AS5F, Brown ESUS-AF, CHA₂DS₂-VASc, CHASE-LESS, HATCH, HAVOC, STAF and SURF.

RESULTS

In univariate analyses increasing age, hypertension, left ventricle hypertrophy, dyslipidaemia, antiarrhythmic drugs usage, valvular heart disease, and neuroimaging findings of stroke due to intracranial vessel occlusions and previous ischemic lesions were associated with a higher likelihood of detected AF. In multivariate analysis, age was the only independent predictor of AF. All the AF-predicting scores showed significantly higher score levels for AF than non-AF patients. The STAF and the SURF scores provided the highest sensitivity and negative predictive values, while the AS5F and SURF reached an area under the receiver operating curve (AUC) > 0.7.

CONCLUSION

Clinical risk scores may guide a personalized evaluation approach in CS patients. Increasing awareness of the usage of available AF-predicting scores may optimize the arrhythmia detection pathway in stroke units.

Underlying causes of cryptogenic stroke and TIA in the nordic atrial fibrillation and stroke (NOR-FIB) study - the importance of comprehensive clinical evaluation

BACKGROUND

Cryptogenic stroke is a heterogeneous condition, with a wide spectrum of possible underlying causes for which the optimal secondary prevention may differ substantially. Attempting a correct etiological diagnosis to reduce the stroke recurrence should be the fundamental goal of modern stroke management.

METHODS

Prospective observational international multicenter study of cryptogenic stroke and cryptogenic transient ischemic attack (TIA) patients clinically monitored for 12 months to assign the underlying etiology. For atrial fibrillation (AF) detection continuous cardiac rhythm monitoring with insertable cardiac monitor (Reveal LINQ, Medtronic) was performed. The 12-month follow-up data for 250 of 259 initially included NOR-FIB patients were available for analysis.

RESULTS

After 12 months follow-up probable stroke causes were revealed in 43% patients, while 57% still remained cryptogenic. AF and atrial flutter was most prevalent (29%). In 14% patients other possible causes were revealed (small vessel disease, large-artery atherosclerosis, hypercoagulable states, other cardioembolism). Patients remaining cryptogenic were younger (p < 0.001), had lower CHA₂DS₂-VASc score (p < 0.001) on admission, and lower NIHSS score (p = 0.031) and mRS (p = 0.016) at discharge. Smoking was more prevalent in patients that were still cryptogenic (p = 0.014), while dyslipidaemia was less prevalent (p = 0.044). Stroke recurrence rate was higher in the cryptogenic group compared to the group where the etiology was revealed, 7.7% vs. 2.8%, (p = 0.091).

CONCLUSION

Cryptogenic stroke often indicates the inability to identify the cause in the acute phase and should be considered as a working diagnosis until efforts of diagnostic work up succeed in identifying a specific underlying etiology. Timeframe of 6-12-month follow-up may be considered as optimal.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT02937077, EudraCT 2018-002298-23.

Atrial fibrillation in cryptogenic stroke and TIA patients in the nordic atrial fibrillation and stroke The Nordic Atrial Fibrillation and Stroke (NOR-FIB) Study: Main results

Introduction:

Secondary stroke prevention depends on proper identification of the underlying etiology and initiation of optimal treatment after the index event. The aim of the NOR-FIB study was to detect and quantify underlying atrial fibrillation (AF) in patients with cryptogenic stroke (CS) or transient ischaemic attack (TIA) using insertable cardiac monitor (ICM), to optimise secondary prevention, and to test the feasibility of ICM usage for stroke physicians.

Patients and methods:

Prospective observational international multicenter real-life study of CS and TIA patients monitored for 12 months with ICM (Reveal LINQ) for AF detection.

Results:

ICM insertion was performed in 91.5% by stroke physicians, within median 9 days after index event. Paroxysmal AF was diagnosed in 74 out of 259 patients (28.6%), detected early after ICM insertion (mean 48 ± 52 days) in 86.5% of patients. AF patients were older (72.6 vs 62.2; p < 0.001), had higher pre-stroke CHA₂DS₂-VASc score (median 3 vs 2; p < 0.001) and admission NIHSS (median 2 vs 1; p = 0.001); and more often hypertension ( p = 0.045) and dyslipidaemia ( p = 0.005) than non-AF patients. The arrhythmia was recurrent in 91.9% and asymptomatic in 93.2%. At 12-month follow-up anticoagulants usage was 97.3%.

Discussion and conclusions:

ICM was an effective tool for diagnosing underlying AF, capturing AF in 29% of the CS and TIA patients. AF was asymptomatic in most cases and would mainly have gone undiagnosed without ICM. The insertion and use of ICM was feasible for stroke physicians in stroke units.

An exploratory study on the effects of an expectancy manipulation on chemotherapy-related nausea

CONTEXT

Previous research has shown that the effectiveness of acupressure bands in reducing chemotherapy-related nausea is related to patients' expectations of efficacy.

OBJECTIVE

To test whether an informational manipulation designed to increase expectation of efficacy regarding acupressure bands would enhance their effectiveness.

METHODS

We conducted an exploratory, four-arm, randomized clinical trial in breast cancer patients about to begin chemotherapy. All patients received acupressure bands and a relaxation CD. This report focuses on Arm 1(expectancy-neutral informational handout and CD) compared with Arm 4 (expectancy-enhancing handout and CD). Randomization was stratified according to the patient's level of certainty that she would have treatment-induced nausea (two levels: high and low). Experience of nausea and use of antiemetics were assessed with a five-day diary.

RESULTS

Our expectancy-enhancing manipulation resulted in improved control of nausea in the 26 patients with high nausea expectancies but lessened control of nausea in 27 patients having low nausea expectancies. This interaction effect (between expected nausea and intervention effectiveness) approached statistical significance for our analysis of average nausea (P=0.084) and reached statistical significance for our analysis of peak nausea (P=0.030). Patients receiving the expectancy-enhancing manipulation took fewer antiemetic pills outside the clinic (mean(enhanced)=12.6; mean(neutral)=18.5, P=0.003).

CONCLUSION

This exploratory intervention reduced antiemetic use overall and also reduced nausea in patients who had high levels of expected nausea. Interestingly, it increased nausea in patients who had low expectancies for nausea. Confirmatory research is warranted.

Preclinical and pilot clinical studies of docetaxel chemoradiation for Stage III non-small-cell lung cancer

PURPOSE

Local and distant failure rates remain high despite aggressive chemoradiation (CRT) treatment for Stage III non-small-cell lung cancer. We conducted preclinical studies of docetaxel's cytotoxic and radiosensitizing effects on lung cancer cell lines and designed a pilot study to target distant micrometastasis upfront with one-cycle induction chemotherapy, followed by low-dose radiosensitizing docetaxel CRT.

METHODS AND MATERIALS

A preclinical study was conducted in human lung cancer cell lines NCI 520 and A549. Cells were treated with two concentrations of docetaxel for 3 h and then irradiated immediately or after a 24-h delay. A clonogenic survival assay was conducted and analyzed for cytotoxic effects vs. radiosensitizing effects of docetaxel. A pilot clinical study was designed based on preclinical study findings. Twenty-two patients were enrolled with a median follow-up of 4 years. Induction chemotherapy consisted of 75 mg/m(2) of docetaxel and 75 mg/m(2) of cisplatin on Day 1 and 150 mg/m(2) of recombinant human granulocyte colony-stimulating factor on Days 2 through 10. Concurrent CRT was started 3 to 6 weeks later with twice-weekly docetaxel at 10 to 12 mg/m(2) and daily delayed radiation in 1.8-Gy fractions to 64.5 Gy for gross disease.

RESULTS

The preclinical study showed potent cytotoxic effects of docetaxel and subadditive radiosensitizing effects. Delaying radiation resulted in more cancer cell death. The pilot clinical study resulted in a median survival of 32.6 months for the entire cohort, with 3- and 5-year survival rates of 50% and 19%, respectively, and a distant metastasis-free survival rate of 61% for both 3 and 5 years. A pattern-of-failure analysis showed 75% chest failures and 36% all-distant failures. Therapy was well tolerated with Grade 3 esophagitis observed in 23% of patients.

CONCLUSIONS

One-cycle full-dose docetaxel/cisplatin induction chemotherapy with recombinant human granulocyte colony-stimulating factor followed by pulsed low-dose docetaxel CRT is promising with regard to its antitumor activity, low rates of distant failure, and low toxicity, suggesting that this regimen deserves further investigation.

Phase II study of induction docetaxel/cisplatin with rhG-CSF followed by concurrent pulsed docetaxel chemoradiation for stage III non-small cell lung cancer (NSCLC)

17034

Background: Both local and distant failures contribute to poor outcome in chemoradiation (CRT) for stage III NSCLC. Our previous study applied pulsed low-dose paclitaxel CRT for stage III NSCLC yielded 97.6% in-field tumor control and a modest survival gain. A follow-up study was designed to target distant micrometastasis up-front by one-cycle induction (IND) chemotherapy (CT) w/o further delay of local therapy. This was followed by low-dose sensitizing docetaxel (Doc) CRT. Methods: IND CT consisted of day 1 Doc 75 mg/m2 & cisplatin 75 mg/m2, and rhG-CSF (150 mg/m2 days 2–10). CRT started 3–6 wks later. Twice-weekly Doc at 12 mg/m2 was given with daily RT of 64.8 Gy to gross dz and 45–57.6 Gy to subclinical dz. Toxicity (Tox), response and survival were assessed. Results: 22 pts enrolled with 16 evaluable. 6 did not complete due to: allergy, intercurrent dz or progressive dz prior-to/during RT. Overall response was 69%. Kaplan-Meier survival was 67%, 55%, and 55% for years 1, 2, and 3. Grade (Gd) 3 Tox of IND CT included: allergy (10%), infection/nl ANC (20%), nausea (10%), HTN (5%) hyperglycemia (5%), H/A (5%), fatigue (10%), dyspnea/gd 4 hyperglycemia/fatigue (5%). No gd 3/4 hematologic Tox. Esophagitis was the main Tox of CRT. Doc was reduced after 10th pt enrolled for high incidence of gd 3 esophagitis: 4/8 (50%) at Doc dose of 12 mg/m2. Subsequent pts received reduced Doc of 10 mg/m2 and 1/8 had gd 3 esophagitis (12.5%). Other gd 3 Tox of CRT included: fatigue (14%), appetite loss (14%), flushing (7%), chest pain (7%), diarrhea (7%), and nausea (28%). No other gd 3 or 4 Tox from CRT. Conclusion: The regimen is associated with low hematologic Tox. Despite published MTD of twice-weekly Doc/RT at 15 mg/m2, 50% treated at 12 mg/m2 had gd 3 esophagitis. This was reduced to 12.5% at 10 mg/m2. Local response was 69% and survival was much better compared with our previous study of pulsed paclitaxel/RT w/o IND CT, which yielded 2 and 3-year survival of 33% and 18% for all, and 40% and 21% for pts completed protocol (Chen et al Clin Cancer Res 9:969–975,2003). Data suggest that one-cycle IND CT followed by low-dose taxane-based CRT improves survival of stage III NSCLC pts and deserves further investigation. Study partly supported by Sanofi-Aventis.

No significant financial relationships to disclose.

Acustimulation wrist bands are not effective for the control of chemotherapy-induced nausea in women with breast cancer

This experiment examined the efficacy of an acustimulation wrist band for the relief of chemotherapy-induced nausea using a randomized three-arm clinical trial (active acustimulation, sham acustimulation, and no acustimulation) in 96 women with breast cancer who experienced nausea at their first chemotherapy treatment. Five outcomes related to wrist band efficacy (acute nausea, delayed nausea, vomiting, QOL, and total amount of antiemetic medication used) were examined. The five outcomes were examined separately using analysis of covariance controlling for age and severity of past nausea. There were no significant differences in any of these study measures among the three treatment conditions (P>0.1 for all). Study results do not support the hypothesis that acustimulation bands are efficacious as an adjunct to pharmacological antiemetics for control of chemotherapy-related nausea in female breast cancer patients.

Effect of paroxetine hydrochloride (Paxil�) on fatigue and depression in breast cancer patients receiving chemotherapy

BACKGROUND

Fatigue can significantly interfere with a cancer patient's ability to fulfill daily responsibilities and enjoy life. It commonly co-exists with depression in patients undergoing chemotherapy, suggesting that administration of an antidepressant that alleviates symptoms of depression could also reduce fatigue.

METHODS

We report on a double-blind clinical trial of 94 female breast cancer patients receiving at least four cycles of chemotherapy randomly assigned to receive either 20 mg of the selective serotonin re-uptake inhibitor (SSRI) paroxetine (Paxil, SmithKline Beecham Pharmaceuticals) or an identical-appearing placebo. Patients began their study medication seven days following their first on-study treatment and continued until seven days following their fourth on-study treatment. Seven days after each treatment, participants completed questionnaires measuring fatigue (Multidimensional Assessment of Fatigue, Profile of Mood States-Fatigue/Inertia subscale and Fatigue Symptom Checklist) and depression (Profile of Mood States-Depression subscale [POMS-DD] and Center for Epidemiologic Studies-Depression [CES-D]).

RESULTS

Repeated-measures ANOVAs, after controlling for baseline measures, showed that paroxetine was more effective than placebo in reducing depression during chemotherapy as measured by the CES-D (p = 0.006) and the POMS-DD (p = 0.07) but not in reducing fatigue (all measures, ps > 0.27).

CONCLUSIONS

Although depression was significantly reduced in the 44 patients receiving paroxetine compared to the 50 patients receiving placebo, indicating that a biologically active dose was used, no significant differences between groups on any of the measures of fatigued were observed. Results suggest that modulation of serotonin may not be a primary mechanism of fatigue related to cancer treatment.

Phase II trial of trimetrexate for patients with advanced gastric carcinoma: an Eastern Cooperative Oncology Group study (E1287)

BACKGROUND

A Phase II study was conducted to evaluate the response, duration of response, and duration of survival of patients with measurable gastric carcinoma treated with trimetrexate (TMTX) who had not had prior chemotherapy.

METHODS

Thirty-three patients with unresectable or metastatic gastric adenocarcinoma who had not received previous chemotherapy were treated with intravenous TMTX 12 mg/m(2) daily for 5 days. The dosage of TMTX was reduced to 8 mg/m(2) daily for 5 days for those who had received prior radiotherapy. The cycle was repeated every 3 weeks until disease progression or unacceptable toxicity occurred.

RESULTS

Thirty-three patients could be analyzed with follow-up data. There was one Grade 5 (lethal) toxicity and four Grade 4 toxicities. Hematologic toxicity was the most common. The overall response rate was 21%, the overall median progression free survival was 2.7 months, and the overall median survival was 5.9 months for the entire cohort. No patients were alive at last follow-up.

CONCLUSIONS

Though TMTX as a single agent has activity in gastric carcinoma with manageable toxicity, it cannot be recommended for routine use as a single agent due to the brief duration of response and median survival.

A phase II study of carboplatin and CHIP in patients with metastatic colon carcinoma

Fifty-six patients were treated in each arm of a study comparing CHIP and carboplatin for the therapy of previously untreated metastatic colorectal carcinoma. There were one partial response (2%) with CHIP and two partial responses (4%) with carboplatin. Side effects were significantly more severe with CHIP than with carboplatin. The most common side effect for both drugs was vomiting followed by hematologic side effects. Sixteen percent of the patients receiving CHIP and 9% of those receiving carboplatin had life-threatening side effects. Neither drug offers significant activity in metastatic colorectal carcinoma.

Spontaneous regression in non-Hodgkin's lymphoma: clinical and pathogenetic considerations

The spontaneous regression (SR) of tumor has been noted in a variety of neoplastic conditions. In non-Hodgkin's lymphoma, this phenomenon has been reported in indolent histologic subtypes, with a frequency of 10-20% in selected series. Investigators evaluating new therapies for lymphomas with a favorable histology need to be cognizant of SR's impact. Mechanisms which have been proposed to explain SR have included the role of contemporaneous bacterial or viral infection, as well as an augmented host immune response which is able to mediate tumor regression via humoral and cellular effector mechanisms. The ability to recapture immunoregulatory control is aptly illustrated by lymphomas developing after organ transplantation where reduction of immunosuppression has, on occasion, resulted in tumor regression. The importance of immune regulation of B-cell lymphoma is also suggested by the tumor's responses to immunotherapy and interferons in vivo and by the biologic and pathologic characteristic of indolent lymphomas being analogous, in may respects, to benign neoplasms. Indolent lymphomas which differ from aggressive lymphomas in their clinical and biological behavior may be more responsive to these host immunoregulatory influences. Review of clinical experience as well as proposed mechanisms of spontaneous regression in non-Hodgkin's lymphoma will be explored in this report.

Acute respiratory distress syndrome with pulmonary calcification in two patients with B cell malignancies

Two patients, one with B cell lymphoma and hypercalcemia and the other with multiple myeloma and hypercalcemia developed acute progressive respiratory insufficiency characteristic of the adult respiratory distress syndrome (ARDS). Both were intubated and placed on mechanical ventilation. Lung compliance deteriorated and became refractory to mechanical inflation. Examination of the lungs at post mortem examination disclosed widespread calcification within alveolar septa and diffuse alveolar damage with hyaline membrane formation consistent with ARDS. Although ARDS has been described with lymphomatous involvement of the lungs, its development in association with metastatic calcification in B cell malignancy has not been previously reported.

Phase I clinical and pharmacokinetic study of diethyldithiocarbamate as a chemoprotector from toxic effects of cisplatin

Diethyldithiocarbamate (DDTC) has been shown to provide protection against most clinically significant toxic effects from cisplatin (DDP) without inhibiting tumor response in a variety of murine animal models. We conducted a phase I clinical and pharmacokinetic study of DDTC in combination with DDP to establish the types and severity of toxic effects and to determine whether protection of normal tissues and tumors occurs. Twenty-two courses of DDP plus DDTC were given to 10 patients. No nephrotoxic effects were seen at DDP doses of 50-120 mg/m2, and three patients had amelioration of nausea and vomiting. Objective antitumor responses were observed. Dose-limiting toxic effects from DDTC occurred at 150 mg/kg; these consisted of numbness in the infusion arm often accompanied by severe diaphoresis, chest discomfort, and agitation during DDTC infusion. These toxic effects resolved spontaneously, however, after termination of the infusion. The preliminary results suggest that plasma levels of DDTC that provide excellent protection in rodents were exceeded at the doses used in our clinical study without compromising antitumor response.

Septicemia, rash, and pulmonary infiltrates secondary to Corynebacterium group JK infection

This report describes a leukemic patient undergoing induction therapy in whom a Corynebacterium JK infection developed while he was leukopenic. The clinical triad of perirectal inflammation, skin lesions, and interstitial lung infiltrates, which has not previously been reported, is discussed. Characteristics of the organism and postulated routes of infection as well as treatment are explored.

Juvenile autoimmune thyroiditis. Hormonal status at presentation and after long-term follow-up

Thirty children and adolescents with the clinical diagnosis of juvenile autoimmune thyroiditis (JAT) were studied. Twenty-six patients were female and four were male. The median age at diagnosis was 12.9 years (range, 7.5 to 17.3 years). At the initial evaluation, endocrine studies revealed that 40% of the patients were euthyroid, while 33% had compensated hypothyroidism and 27% had overt hypothyroidism. Seventeen patients, 16 of whom received thyroid hormone replacement therapy for a median period of 26 months, were followed up on a long-term basis after discontinuation of therapy. Seven (87%) of eight patients who were initially euthyroid have remained so for a median period of 28 months after treatment and a median period of 50 months since diagnosis. Four (44%) of nine patients who initially had hypothyroidism (either compensated or overt) have reverted to a euthyroid state and have remained so for a median period of 33 months after discontinuation of therapy. Neither the size of the thyroid gland nor the pattern or absolute titer of thyroid autoantibodies correlated with functional status. These results indicate that individuals with euthyroid JAT may remain euthyroid for many years and that a substantial percentage of patients with hypothyroid JAT will experience resolution of thyroid dysfunction.

Predictors of mortality in the immunocompromised patient with pulmonary infiltrates

To determine predictors of mortality in immunocompromised patients with pulmonary infiltrates, we reviewed the records of all such patients admitted to two community teaching hospitals who underwent a lung biopsy over a ten-year period. We examined the consequences of advancing age, primary disease, fever, neutropenia, immunosuppressive corticosteroid therapy, previous lung radiation, roentgenographic pattern, result of lung biopsy, room air arterial oxygen pressure (Pao2), early mechanical ventilation, and the presence of a comorbid disease on eventual outcome. We identified 104 episodes in 99 patients. Sixty-seven (64%) survived and 37 died. By both discriminant analysis and logistic regression statistical methods, mechanical ventilation, the initial room air Pao2, and corticosteroid therapy were the dominant independent variables, in that order, to significantly predict mortality. No patient survived who simultaneously had a room air Pao2 less than or equal to 50 mm Hg, was on corticosteroids, and was mechanically ventilated. Eighty-three percent of survivors had either none or, at most, one of these three variables present. We conclude that hypoxia, immunosuppression by corticosteroids, and the necessity for mechanical ventilation within 72 hours of hospitalization indicate a poor prognosis in the immunocompromised patient with pulmonary infiltrates who has undergone a lung biopsy.

Combination chemotherapy for advanced colorectal cancer. A pilot study

Twenty-three patients with advanced colorectal carcinoma, mostly with liver and lung metastases and measurable disease, were treated with mitomycin-C 20 mg/m2 I.V. and vincristine 1.2 mg/m2 I.V. every 6 weeks, and cisplatinum 50 mg/m2 I.V. and 5-fluorouracil 1,000 mg/m2/24 hours I.V. continuous infusion for 96 hours every 3 weeks based upon the hypothesis that cisplatinum may potentiate the antitumor activity of antimetabolites and alkylating agents. Five patients had received prior chemotherapy and six had received prior radiotherapy, with one of these patients receiving both. One complete and 10 partial responses were observed, with an overall response rate of 48% (90% confidence interval 30-70%). The toxicity was manageable. A possible potentiating effect of cisplatinum is suggested in this first attempt in the treatment of colorectal cancer, and warrants further exploration.

Sensitivity, specificity, and predictive values of bronchoscopy in neoplasm metastatic to lung

Bronchoscopic examination to diagnose lung metastases has not been as rewarding as in primary lung cancer. Despite a lower expected yield, we believe the procedure has value in certain patients, ie, those with clinical findings of endobronchial disease. To determine better the value of bronchoscopy in this population, we retrospectively reviewed records of patients at five community teaching hospitals over a 66-month period. These patients all underwent fiberoptic bronchoscopy. They had a history of prior nonpulmonary malignancy and an abnormal chest roentgenogram suspicious for recurrent malignant disease, or they presented with abnormal chest roentgenographic findings and further evaluation showed the lung disease to be metastatic. Bronchoscopy for metastatic lung disease was most likely diagnostic in patients with primary colorectal cancer (79 percent) and breast cancer (57 percent), and least likely in patients with genitourinary tract cancer (33 percent). Hemoptysis, signs of local airway obstruction, or a roentgenogram showing either atelectasis or diffuse lung disease especially favored a positive biopsy. Bronchoscopy is a valuable diagnostic procedure in selected patients with metastatic lung disease.

Preoperative radiation therapy with sensitizers in the management of carcinoma of the rectum

There is enough evidence to show that adjuvant radiation therapy contributes to the management of patients with carcinoma of the rectum. In an effort to improve resectability and possibly survival rates, the use of chemosensitizers, combined with moderate doses of radiation used presurgically, was introduced for carcinomas larger than 5 cm in diameter requiring abdominoperineal resection. Based on our experience and that of others, it is believed that the method of administration of 5FU and mitomycin-C is an important factor in obtaining an increased therapeutic ratio. Because of the locoregional pattern of spread of rectal cancer, this adjuvant approach would appear suitable. A series of approximately 60 patients is discussed and the surgical findings and five-year survival is reported.

Estrogen receptors and the pattern of relapse in breast cancer

To determine if the pattern of relapse in patients with breast cancer was influenced by the presence or absence of hormonal receptors, we examined 300 patients with breast cancer who had estrogen receptor (ER) assays performed on their primary tumors. A multivariate discriminant analysis of the initial site of recurrence was performed, and we included in the analysis such factors as ER status, menopausal status, axillary lymph node involvement, and the interaction between menopausal status and ER status. Estrogen receptor status was found to be the single most important independent variable associated with the pattern of recurrence. There was significantly higher likelihood of visceral metastasis with ER-negative tumors, 52.1% as opposed to 5.38% for ER-positive tumors. Conversely, there was a high frequency of osseous relapse with ER-positive tumors, 60.4%, as opposed to 13.4% for ER-negative tumors. We also found that postmenopausal women tended to be ER positive more often than premenopausal women, and progesterone receptor status appears to be a good indicator for five-year disease-free survival in patients without axillary node involvement. With the progression of disease, there was a loss of receptors, even without therapeutic intervention.

Survival of patient with pleural involvement by breast carcinoma

To determine factors which affect survival in patients with pleural involvement by breast carcinoma, we reviewed records of all patients at two community teaching hospitals presenting with malignant pleural effusion over a 6-year period. Forty-five patients had had mastectomy for breast cancer, no history of other malignancy, and cytologic confirmation of subsequent pleural metastases. All had received conventional combination systemic chemo- or hormonal therapy. Ten patients (group 1) in whom effusion was the initial and only site of recurrent disease had a median survival of 48 months. The median survival was 12 months in 35 patients (group 2) who developed effusion in association with other metastatic disease. Half of the patients in group 1 had no axillary node involvement at mastectomy. Twenty-eight patients (80%) in group 2 had had more advanced disease at initial diagnosis. This, and behavior of the effusion as regional rather than systemic disease, suggested by the high incidence of effusion on the ipsilateral side of the mastectomy, probably accounts for the better outlook in patients with effusion alone.

Phase II study of cisplatin for metastatic prostatic carcinoma. An Eastern Cooperative Oncology Group study

In a phase ii trial 18 previously treated patients with metastatic prostatic carcinoma with measurable or evaluable disease were treated with cisplatin 50 mg/m2 every 3 weeks. Treatment was well tolerated in this elderly group of patients except for GI toxicity seen in 75% of the patients. There were no objective responses. Changes in serum acid phosphatase were often transient and not accompanied by clinical improvement. Cisplatin does not appear to be an effective agent in metastatic prostatic carcinoma in the dose schedule employed.

Peritoneovenous shunt for palliation of malignant ascites

Forty patients with malignant ascites refractory to conventional medical management had peritoneovenous shunt for palliation. The shunt provided effective palliation in 28 with decrease in weight, abdominal girth, number of paracenteses required and increase in urine output. These patients also had improvement in strength, appetite and ambulation. Complications such as hemodilution, volume overload, and sepsis do not contraindicate surgery. In 12 patients with high ascitic fluid protein content (4.5 g/liter) and a large number of malignant cells, loculated ascites and prior severe renal and cardiac disease, the shunt did not provide palliation. Peritoneovenous shunt appears to provide effective palliation in carefully selected patients with refractory malignant ascites.

Combination chemotherapy for advanced colorectal cancer with triazinate, ICRF-159, 5-FU, and methyl-CCNU

Twenty-four patients with advanced metastatic colorectal cancer with measurable sites of disease were treated with a combination of 5-FU, methyl-CCNU, ICRF-159, and triazinate. Only two had objective regression of disease. Two patients died of complications from drug-induced myelosuppression. Toxic effects were moderate in the remaining patients. Attempts to escalate doses were limited by myelosuppression. The regimen used has no advantage over 5-FU alone. It is unlikely that triazinate and ICRF-159 will add substantially to the efficacy of chemotherapy for colorectal cancer.

Malignant lymphoma of the skin: a clinicopathologic study of lymphoma other than mycosis fungoides

The clinical and histopathologic findings in 25 cases of malignant lymphoma of the skin other than mycosis fungoides were reviewed. All patients had skin lesions as a primary manifestation of the disorder, and none had histopathologic evidence of extracutaneous involvement at the time of skin biopsy. The majority of patients had solitary nodules involving the skin of the head and neck region. Twenty-two of the skin biopsy specimens were interpreted as lymphocytic lymphoma, well or poorly differentiated, nodular or diffuse. Only three cases of histiocytic lymphoma (reticulum cell sarcoma) were encountered, and there were no cases of Hodgkin's disease of the skin. Twenty-two patients (88%) subsequently developed extracutaneous lymphoma: the interval from the occurrence of apparently localized skin lesions to involvement of lymph nodes and/or viscera ranged from 6 months of 5 years (mean duration of 21 months). Sixteen patients (64%) died of disseminated lymphoma, with survivals that ranged from 8 months to 12 years (mean survival of 3.7 years). Only three patients survived without disease for greater than 1 year. There was no definite relationship between either the histologic subtype of the tumor or the mode of therapy and prognosis. The patholoic findings indicate that a definite diagnosis of malignant lymphoma can be made by skin biopsy in patients with disease apparently confimed to the skin. Careful, detailed examination of the skin biopsy specimen provides a basis for distinguishing malignant lymphoma from cutaneous lymphoid hyperplasia. The clinical findings and survival data support the conclusion that malignant lymphoma with skin lesions as a primary manifestation almost invariably disseminates to extracutaneous organs and usually has a fatal outcome.

Improved survival in hodgkin's disease

All patients below the age of 66 whose Hodgkin's disease was treated at the Massachusetts General Hospital between July 1, 1965 and June 30, 1973 were analyzed. The patients were divided into an early group seen before November 1, 1968 and a later group seen after that date. Survival and survival without recurrence were calculated by the actuarial method of Berkson and Gage, and compared with figures obtained from a historical series seen at this institution between 1948 and 1964. In the most recent period (1969-1973), 87% of patients with all stages of Hodgkin's disease were alive five years after diagnosis, a remarkable improvement over the 65% survival of the 1965-1968 group and the 34% survival of the historical series. The excellent survival of the recent group was a result of improved management of patients with advanced disease (Stages III and IV), most plausibly attributed to better appreciation of the extent of disease by surgical staging and to the shift from total nodal irradiation to combination chemotherapy for initial treatment of these patients. Recurrence after irradiation was extremely uncommon in patients in Stage IA and IIA (lymphangiogram-negative, asymptomatic) subjected to aging laparotomy, while similarly staged and irradiated patients in Stages IB and IIB (lymphangiogram-negative, symptomatic) did much less well. Except for the surgically staged patients in Stages IA and IIA, the continuing high relapse rate indicates that five-year survival, even when relapse-free, is not synonymous with cure, and emphasizes the need for caution in predicting the ultimate cure rate with current therapy.

The natural history of nodular lymphoma

The clinical and histopathologic characteristics of 65 patients with nodular lymphoma seen at the Massachusetts General Hospital between 1962 and 1972 were reviewed. Five years after diagnosis 54% of these patients were alive, but only 18 percent remained free of disease. Younger patients fared much better (64 percent of those below the age of 50 survived 5 years) than the elderly (only 34 percent of those above the age of 50 survived this long), but histologic subtype by the Rappaport classification was not useful in predicting survival in this series. Individuals with localized disease (80% of those in Stages I and II survived 5 years) experienced better survival than those with dissemination (only 45% of those in Stages III and IV lived this long), but the high relapse rate in Stages I and II indicates that few who presented with localized disease are cured. At the time of death, the histologic pattern had become diffuse in 8 of 18 patients but remained nodular in the other 10. Ten patients treated by total nodal irradiation followed the same survival curve as the remainder treated less radically. It is concluded that nodular lymphoma is an indolent but usually fatal entity: though more than half of our patients survived 5 years, few were cured by the treatments employed.