Dose-dense Chemotherapy in Metastatic Gastric Cancer with a Modified Docetaxel-Cisplatin-5-Fluorouracil Regimen

Aims and background

Previous studies have reported that in early breast cancer, lymphomas and advanced bladder cancer, dose-dense chemotherapy may be more effective than conventional treatments. In metastatic gastric cancer, chemotherapy with docetaxel, cisplatin and 5-fluorouracil (TCF) q3w is very active, and, even though there is no international consensus on the subject, it is the regimen of choice of many European centers as first-line chemotherapy in this subset of patients. Based on these studies, we tested for the first time the feasibility and activity of an intensified dose-dense TCF regimen (q2w) modifying the 5-fluorouracil infusion with l-folinic acid/5-fluorouracil according to the “De Gramont regimen”.

Methods and study design

Patients with histologically confirmed measurable metastatic gastric cancer, ECOG performance status ≤1, and not previously treated for advanced disease received docetaxel, 85 mg/m2 (75 mg/m2 after the first 6 patients, 70 mg/m2 after the 19th patient) on day 1, cisplatin, 75 mg/m2 on day 1 (60 mg/m2 after the 19th patient), l-folinic acid, 100 mg/m2 on days 1 and 2, followed by 5-fluorouracil, 400 mg/m2 bolus on days 1 and 2 and then 600 mg/m2 as a 22-h continuous infusion on days 1 and 2, every 14 days, plus pegfilgrastim, 6 mg on day 3. Patients aged ≥65 years received the same schedule with a dose reduction of 30%.

Results

Thirty-two consecutive patients were enrolled (63% male, 37% female); median age, 64 years (range, 40–81). A median of 4 cycles (range, 1–7) per patient was administered. Eleven of 32 patients (34%) required a dose reduction, mostly for hematological grade III-IV toxicity and severe asthenia. Twelve patients (38%) completed the first 4 cycles of therapy within 7 weeks, thereby finishing without delay the initially planned dose-density schedule. Twenty-eight patients were evaluated for response (1 early suspension after the first cycle because of toxicity, 3 deaths before response evaluation due to progression of disease). There were 3 complete responses (9%), 15 partial responses (47%), 7 stable disease (22%) and 3 progression of disease (9%), for an overall response rate, by intention to treat, of 56% (95% CI, 39–73). The most frequent grade 3–4 toxicities were: neutropenia (53%), thrombocytopenia (34%), anemia (16%) febrile neutropenia (22%), asthenia (38%) and diarrhea (19%). Median time to progression was 9.1 months (95% CI, 6.0–12.2); median overall survival was 10.1 months (95% CI, 8.8–12.2).

Conclusions

A dose-dense TCF regimen in metastatic gastric cancer is feasible, with activity comparable to previous results achieved with epirubicin-based chemotherapy and TCF q3wk in terms of overall survival and time to progression, and deserves to be further tested in randomized phase III studies.

An Autoimmune Haemolytic Anaemia Secondary to Ipilimumab Treatment

BACKGROUND

Melanoma is one of the fastest growing neoplasms worldwide. Treatment of metastatic disease has swiftly shifted in the last decade from generally ineffective chemotherapy regimens to highly effective targeted treatments or immunotherapy, with a range of side effects that differ completely from those of previous treatments for this disease.

CASE

We present a case of a 71-year-old man with diagnosis metastatic melanoma. This patient was treated with anti-CTLA-4 antibody ipilimumab. Despite minor skin toxicity, the regimen was well tolerated until he developed hemolytic anemia, an autoimmune side effect of ipilimumab. The treatment was withdrawn and steroids were administered until the issue was resolved.

CONCLUSION

Immunotherapy has become the standard of care for many tumors, and its side effects are completely different from those of chemotherapy, meaning that oncologists must be aware of this to avoid a potentially life-threatening situation and arrive at an early diagnosis and implement prompt treatment.Key words: anemia - autoimmune event - anti-CTLA-4.

Sentinel Lymph Node in Melanoma - a Study Conducted in the South of Brazil

BACKGROUND

The presence or absence of lymph node metastases is a very important prognostic factor for survival and recurrence in patients with cutaneous melanoma. Controversies remain among specialists about whether it is advisable or not to perform a sentinel lymph node biopsy in patients with melanoma, although it is currently supported by most standard guidelines. We performed this study to identify which patients are more prone to having a positive lymph node test result in a population with high melanoma rates in the south of Brazil.

MATERIALS AND METHODS

We performed the study with 62 consecutive patients who underwent sentinel lymph node biopsies from 2003 to the early months of 2015 in the city of Blumenau - Santa Catarina, Brazil.

RESULTS

Breslow thickness, ulceration, nodular subtype, and Clark level IV were associated with positive sentinel lymph node group status (p 0.05).

DISCUSSION

Although there is still a controversy over whether or not this procedure should be performed, most guidelines still support its application. To lower the economical and physical impact, however, it is worthwhile to determine which patients are more prone to acquiring positive lymph node at presentation and, perhaps, in the future, indicate surgery for this particular group, who could benefit most from further treatment options.

KEY WORDS

melanoma - sentinel lymph node biopsy - prognosis.

Melanoma patterns of distant relapse: a study of 108 cases from a South Brazilian center

BACKGROUND

The incidence of cutaneous melanoma has increased over the last decades. Recurrences occur most frequently within the first 2-3 years after diagnosis but patients carry a lifelong risk of relapse. Nevertheless, there is no consensus in the literature on what screening tests patients should undergo.

OBJECTIVES

To evaluate the most common melanoma metastasis sites among a South Brazilian population from a city with one of the highest melanoma rates, and establish the best screening method for these patients.

METHODS

A cross-sectional retrospective study of 108 consecutive melanoma patients followed up at a center from 2009 to 2013. Data were collected on demographic and tumoral characteristics, as well as the site of the first diagnosed metastasis.

RESULTS

Patients were divided into 3 groups for analytical purposes: Non-visceral metastases (48% of patients), visceral metastasis (39%) and brain metastasis (13%). We tried to correlate age, gender, mean Breslow thickness, mitosis and death rates with the aforementioned groups but none showed any statistically significant association.

CONCLUSION

Melanoma patients must be monitored to detect early relapse and subsequent effective treatment but the best follow-up strategy remains to be established.

Safety and efficacy of the combination of T-DM1 with radiotherapy of the central nervous system in a patient with HER2-positive metastatic breast cancer: case study and review of the literature

Approximately 35% of patients with confirmed HER2 breast cancer progress to metastases of the central nervous system (CNS). Total cerebral radiotherapy is considered as standard treatment for these cases; however, studies have shown that some chemotherapy drugs can be used during radiotherapy without significantly increasing its toxicity. In this article, we report the case of a patient with HER2-positive breast cancer who showed isolated progression of the illness in the CNS, which was observed during the treatment period using T-DM1 concomitantly with radiotherapy of the CNS without apparent toxicity of the combination and keeping the illness controlled. Through a review of the literature on the use of radiotherapy and chemotherapy with T-DM1 for the treatment of cerebral metastases in HER2-positive breast cancer, we describe the efficacy and tolerance of the concomitant application of these treatments.

Epidemiology of melanoma in the South of Brazil: study of a city in the Vale do Itajaí from 1999 to 2013

BACKGROUND

Cutaneous melanoma is a highly aggressive malignancy with increasing incidence worldwide. The southern Brazilian state of Santa Catarina has one of the highest incidence rates of melanoma in the country.

OBJECTIVE

To evaluate the epidemiological profile of melanoma patients in a southern city of Brazil.

METHODS

a cross-sectional retrospective study was conducted, aiming to detect the clinical and histopathological characteristics of cutaneous melanoma diagnosed in the city of Brusque - SC, between 1999 and 2013.

RESULTS

A total of 213 cases in 212 individuals were studied. More than 50% of the patients were females (p< 0.05). The trunk was the most commonly affected site (p< 0.05), followed by the upper limbs. Nodular and superficial spreading melanomas were the most commonly detected in histological analyses. They did not differ statistically in frequency, but were more prevalent than other histopathological subtypes (p< 0.05). There was no statistically significant difference between invasive and noninvasive melanomas (p= 0.2441). Among the invasive melanomas, those with Breslow thicknesses < 1 mm and between 1-2mm were more prevalent (p< 0.05).

CONCLUSIONS

In this study we found a higher frequency of melanomas in female patients and patients aged over 51. The trunk was the most commonly affected site. Nodular and superficial spreading melanomas prevailed. Among invasive melanomas, those with Breslow thicknesses < 2 mm were the most frequent. This paper highlights the epidemiological profile of melanoma patients in the city and may help to identify and aid in the follow-up of those who are most likely to present the disease.

A rare neoplastic growth on the ear lobe

We report a case of an 83-year-old previously healthy female patient presenting with a swiftly evolving erythematous violaceous, infiltrative, ulcerated onion like mass with hyperkeratotic surface on the left ear lobe. The lesion was excised and resulted as an atypical fibroxanthoma, an extremely rare neoplastic growth, being a superficial variant of pleomorphic malignant fibrous histiocytoma. A brief review of dia-gnosis, treatment and prognosis is discussed.

[Cervical adenocarcinoma with lymphatic spread presenting as carcinoma "en cuirasse"of the vulva: case report]

We report the case of a patient with carcinoma "en cuirasse" of the vulva.

CASE REPORT

A female patient presented complaining of inguinal lymphadenopathy. Lymph node excision, immunohistochemistry analyses, and further exams showed the presence of cervical adenocarcinoma. The cancer was surgically removed and the patient was treated with radiotherapy and chemotherapy with a good initial response. Some months later she presented with intense edema of the lower limbs, hardening and thickening of the labia majora, and pelvic and genital ulceration. A cutaneous biopsy with subsequent immunohistochemical staining showed lymphatic dissemination of adenocarcinoma to the vulva.

DISCUSSION

Carcinoma "en cuirasse" is a rare presentation of cutaneous metastasis in which the affected skin shows hardening and induration, acquiring a sclerodermoid appearance. This is, to the best of our knowledge, the first report in Brazil of carcinoma "en cuirasse" of the vulva associated with cervical adenocarcinoma.

Wage -specific assessment of mammography screening in Brazilian women

OBJECTIVE

Mammography is an inexpensive examination that has become a standard screening method thanks to its cost-effectiveness. Due to an enormous cost escalation of cancer treatment over the last years, the assessment of this method, especially in the settings of an emerging country, is a matter of serious concern.

METHODS

A search within the national health database was conducted registering the data with nation- wide coverage. Data collection and analysis was commenced in 2010 with referrence to the year 2008 as the most recently updated period. The obtained information on mammography screening among Brazilian women was evaluated by subdividing the data in four groups according to socioeconomic status of the subjects. The study population was estimated to comprise about 2 million individuals.

RESULTS

More than 45% of Brazilian women older than 40 years of age have never undergone a mammography. The figures correlated with the income level, reaching an astonishing number of 62.2% in a group of patients with the lowest income level.

CONCLUSION

Mammography has proved effective in early detection of breast cancer in women. This study suggests that the lack of compliance in breast cancer screening in Brazil, pronounced especially in low- income families, may contribute to the increasing mortality rates associated with the disease.

Multiple myeloma with testicular involvement: a case report and review of the literature

We report a case of a very unusual metastasis of multiple myeloma to the testis in a 53-year-old-patient, documented with images and anatomic-pathological exam. Our case report is of interest because it is one of the rarest forms ever reported of advanced multiple myeloma.

Bevacizumab as secondline treatment of glioblastoma - worth the effort?

OBJECTIVE

To evaluate the role of bevacizumab and irinotecan as secondline treatment of glioblastoma in patients with progression after radiotherapy and temozolomide.

METHODS

A retrospective analysis of 16 subjects was performed with overall survival and toxicity evaluation as the primary endpoint.

RESULTS

The analysis revealed serious toxicity of this highly expensive regimen without proving an improvement in overall survival of patients in comparison to a control group.

CONCLUSION

Unless there are robust data from phase III clinical trials, including quality of life assessments or evaluation of predictive bio-markers to guide therapy, bevacizumab and irinotecan regimen should be spared for cautiously selected patients, especially in countries with limited budget for oncological treatment.

Changes in lymphocyte count induced by repeated cycles with low-dose interleukin-2 and interferon-α in 146 patients with renal cell carcinoma

AIMS AND BACKGROUND

The exact mechanism by which recombinant interleukine-2 and interferon-α modulate the immunological response, inducing long-term responses in metastatic renal cell carcinoma, is still not clear. The aim of the study was to analyze the modifications in peripheral blood lymphocytes during cycles of low-dose immunotherapy as a marker of the biological response to the treatment in 146 patients with renal cell carcinoma (advanced and localized disease).

METHODS AND STUDY DESIGN

Peripheral blood lymphocytes were evaluated before and after every cycle of treatment.

RESULTS

We found a statistically significant overall difference between pre- and post-cycle values (mean increase of 39%). The differences between pre- and post-cycle lymphocyte counts for each cycle were significant. Also, the post-cycle lymphocyte count of each cycle remained higher than the baseline value. Furthermore, pre-cycle lymphocyte counts of each cycle were still higher than the baseline value, with no difference between a pre-cycle lymphocyte mean value and the other one (except that between the first and second cycle). From the end of each cycle, but before starting the next one, the absolute value of lymphocytes fell on the average by 15-30%, concurring with the fact that, even starting from pre-cycle values higher than baseline, the immune system remains sensitive to chronically repeated stimulation by immunotherapy. We also found that non-metastatic patients had a higher number of peripheral blood lymphocytes than metastatic patients, whereas the latter had a lower immune response to therapy.

CONCLUSIONS

The results support the idea that "maintenance" immunotherapy may not develop resistance over time in terms of biological response and thus may have a role as chronic therapy in combination with other drugs such as target therapy. We suppose that the immune system of patients with metastases is in a state of relative impairment, resulting in less sensitivity to immunostimulating agents.

Pericardial breast cancer metastasis 25 years after mastectomy

Pericardial effusion in a patient with a history of cancer should always prompt a hypothesis of malignant involvement. We report the case of a 66-year-old white woman presenting with pericardial effusion 25 years after a mastectomy for ductal breast carcinoma. This is one of the cases with the latest recurrence ever reported.

Pericardial Breast Cancer Metastasis 25 Years after Mastectomy

Pericardial effusion in a patient with a history of cancer should always prompt a hypothesis of malignant involvement. We report the case of a 66-year-old white woman presenting with pericardial effusion 25 years after a mastectomy for ductal breast carcinoma. This is one of the cases with the latest recurrence ever reported.

Changes in Lymphocyte Count Induced by Repeated Cycles with Low-Dose Interleukin-2 and Interferon-α in 146 Patients with Renal Cell Carcinoma

Aims and Background

The exact mechanism by which recombinant interleukine-2 and interferon-a modulate the immunological response, inducing long-term responses in metastatic renal cell carcinoma, is still not clear. The aim of the study was to analyze the modifications in peripheral blood lymphocytes during cycles of low-dose immunotherapy as a marker of the biological response to the treatment in 146 patients with renal cell carcinoma (advanced and localized disease).

Methods and Study Design

Peripheral blood lymphocytes were evaluated before and after every cycle of treatment.

Results

We found a statistically significant overall difference between pre- and post-cycle values (mean increase of 39%). The differences between pre- and post-cycle lymphocyte counts for each cycle were significant. Also, the post-cycle lymphocyte count of each cycle remained higher than the baseline value. Furthermore, pre-cycle lymphocyte counts of each cycle were still higher than the baseline value, with no difference between a pre-cycle lymphocyte mean value and the other one (except that between the first and second cycle). From the end of each cycle, but before starting the next one, the absolute value of lymphocytes fell on the average by 15–30%, concurring with the fact that, even starting from pre-cycle values higher than baseline, the immune system remains sensitive to chronically repeated stimulation by immunotherapy. We also found that non-metastatic patients had a higher number of peripheral blood lymphocytes than metastatic patients, whereas the latter had a lower immune response to therapy.

Conclusions

The results support the idea that “maintenance” immunotherapy may not develop resistance over time in terms of biological response and thus may have a role as chronic therapy in combination with other drugs such as target therapy. We suppose that the immune system of patients with metastases is in a state of relative impairment, resulting in less sensitivity to immunostimulating agents.

Sigmoid adenocarcinoma with renal metastasis

We report a case of a 75-year-old man submitted to a rectosigmoidectomy and partial cystectomy because of a sigmoid cancer and colovesical fistula. Seven months later and after four cycles of adjuvant chemotherapy, a lesion was detected in the kidney. Histology revealed tubular adenocarcinoma, which meant sigmoid cancer metastasis. Kidney metastases are very rare in colorectal cancer (CRC), but may be generally associated with an unfavorable prognosis. Thus, patients with metastatic CRC and kidney tumors are a diagnostic and therapeutic challenge.

Basal-like immunophenotype markers and prognosis in early breast cancer

AIMS AND BACKGROUND

Basal-like breast cancer is a distinct group of tumors with heterogeneous behavior, and not all have a poor prognosis. The present study analyzed the prevalence and prognosis of early basal-like breast cancer.

METHODS AND STUDY DESIGN

A total of 112 patients with stage I and II breast cancer were retrospectively analyzed using immunohistochemical stains for estrogen receptor, progesterone receptor, HER2, cytokeratin 5/6 and epidermal growth factor receptor. Basal-like tumors were defined as being estrogen receptor, progesterone receptor and HER2 negative and cytokeratin 5/6 and/or epidermal growth factor receptor positive.

RESULTS

Of the 112 cases, respectively 13 (11.6%) were basal-like, 77 (68.8%) luminal A or B, 13 (11.6%) HER2 positive and 9 (8%) undefined. In basal-like tumors, epidermal growth factor receptor and cytokeratin 5/6 expression was positive in 5 patients (38.5%) and 12 patients (92%), respectively. There was no significant correlation between basal-like breast cancer and age (P = 0.207), lymph node status (P = 1.0) or clinical stage (P = 0.53). Among all tested biomarkers, positivity was found in 81 (72.3%) for estrogen receptor, 13 (11.6%) for HER2, 11 (9.8%) for epidermal growth factor receptor and 36 (32.1%) for cytokeratin 5/6. Epidermal growth factor receptor expression was significantly correlated with estrogen receptor-negative (P = 0.01) and HER2-positive (P = 0.02) tumors. During a median follow-up of 81 months, there were 26 (23%) disease relapses and 12 (10.7%) deaths. No significant difference relating to disease-free survival and overall survival was noted between basal-like breast cancer and subtypes luminal A and B, HER2 positive and undefined.

CONCLUSIONS

The addition of cytokeratin 5/6 and epidermal growth factor receptor defines a small subgroup of patients with basal-like tumors. In a population with early breast cancer, basal-like tumors did not have a prognosis different from the other subtypes. Neither was there a significant association with clinicopathological features. The high frequency of epidermal growth factor receptor positivity in estrogen receptor-negative and HER2-positive tumors represents a potential target in clinical trials.