Low-dose nivolumab and cabozantinib in recurrent intestinal-type papillary adenocarcinoma of the sinonasal region

Intestinal-type sinonasal adenocarcinoma is a rare epithelial malignancy primarily treated with surgery and chemoradiation. The combination of low-dose immunotherapy and a tyrosine kinase inhibitor in recurrent disease has not been previously studied.A man in his 20s with papillary adenocarcinoma of the sinonasal region, following surgical resection, was treated with six cycles of concurrent chemoradiotherapy, followed by four cycles of docetaxel, cisplatin and capecitabine. While on treatment, he was found to have extensive residual disease and he was started on low-dose nivolumab and cabozantinib. Repeat imaging after ten months of treatment revealed a significant reduction in lesions.Non-squamous head and neck cancers are often excluded from major trials, and the effect of immunotherapy in these histologies is poorly understood. The response seen with low-dose immunotherapy underscores the need for further research in this setting.

Use of apatinib combined with pemetrexed for advanced ovarian cancer: A case report

INTRODUCTION

Ovarian cancer is the most deadly gynecologic cancer, and the therapy is very difficult. Apatinib is a novel tyrosine kinase inhibitor targeting vascular endothelial growth factor receptor-2. At present, there are few studies or case reports on apatinib treatment for patients with ovarian cancer.

CASE PRESENTATION

A 75-year-old Chinese woman had a medical history of ovarian high-grade serous papillary adenocarcinoma, who got many lines of chemotherapy and apatinib-an antiangiogenesis drug therapy. Either alone or in combination, apatinib may extend the survival time of patients with advanced ovarian cancer.

CONCLUSION

Apatinib may be an option for advanced ovarian cancer after failure of chemotherapy or other targeted therapy. The role of apatinib in the treatment of advanced ovarian cancer needs further study.

[A case of small bowel cancer with positive peritoneal cytology and five-year recurrence-free survival]

Small bowel cancer is frequently detected at an advanced stage and its prognosis is poor. We report on a patient with small bowel cancer with positive peritoneal cytology who survived for 5 years without recurrence after surgery.The case involved a 73-year-old woman who had undergone partial resection of the small intestine and lymphadenectomy for a small bowel tumor with obstruction. Pathological examination confirmed papillary adenocarcinoma with partial serosal invasion. Ascites cytology indicated a class V tumor. Adjuvant chemotherapy with TS-1 was administered for 20 months, and the patient has survived without evidence of disease for over 5 years.In this case, it is possible that TS-1 chemotherapy was effective for prevention against small bowel cancer recurrence.Furthermore , peritoneal cytology in patients with small bowel cancer should be evaluated as a predictor of prognosis.

Papillary-serous adenocarcinoma of the uterine cervix during tamoxifen therapy after bilateral breast cancer

BACKGROUND

Papillary-serous adenocarcinoma (PSCC) is a very rare subtype of cervical cancer. To our knowledge, this is the first report on PSCC of the uterine cervix following bilateral breast cancer.

CASE REPORT

A 61-year-old Caucasian woman underwent conserving surgery of both breasts at the age of 57 years, because of bilateral invasive ductal carcinoma. Radiation and tamoxifen treatment followed. Routine surveillance examinations, including pelvic examination, Papanicolaou (Pap) smear, and transvaginal ultrasound, were uneventful. Recently, a small contact-bleeding mass of the cervix was found. The Pap smear was II (reactive); HPV-DNA test was negative. The biopsy of the mass revealed PSCC with a high expression of p53, carcinoembryonic antigen (CEA), and Ki67 (50%). Staining for estrogen receptor (ER), progesterone receptor (PR), and vimentin was negative. The serum carbohydrate antigen 125 (CA-125) reached 159 U/ml. The patient was treated with radical hysterectomy, bilateral salpingo-oophorectomy, and pelvic and paraaortic lymphadenectomy. A poorly-differentiated papillary-serous, non-secretory adenocarcinoma, pT1b1, pN0 (0/44), pM0, G3, R0, V0, L0, was confirmed. According to the German recommendations for early-stage cervical cancer, the patient received no adjuvant treatment. Currently, the patient is free of relapse 38 months after the diagnosis of cervical cancer and 87 months after that of breast cancer.

CONCLUSION

Immunohistochemistry is helpful in diagnosing rare entities. This case adds further evidence that the prognosis for early-stage PSCC is probably not poorer than that for other cervical adenocarcinomas.

Primary fallopian tube carcinoma with metastasis in the contralateral ovary

Primary malignant neoplasm of the fallopian tube is one of the rarest gynaecological malignancies and a pre-operative diagnosis is often missed due to its diagnostic confusion with the tubo-ovarian mass, hydrosalpinx, ectopic pregnancy and ovarian malignancy. Transcoelomic, lymphatic, transluminal and haematogenous spread may occur to the other abdominal and pelvic organs as well as to the distant sites. Though the body of the uterus, ovaries and the contralateral fallopian tube are frequently involved, in the present case the contralateral ovary was the only site of involvement which is very unusual.

[A case of primary breast cancer responding to pre-operative chemotherapy with the combination of paclitaxel and carboplatin for ovarian cancer]

A 62-year-old woman was diagnosed with primary left breast cancer during a follow-up for an ovarian tumor. She had at first undergone surgical resection of an ovarian tumor, and a pathological examination had revealed ovarian cancer. Gynecologists decided to treat her ovarian cancer with chemotherapy, and we were initially planning to provide treatment for breast cancer after that was completed. Sentinel lymph node biopsy performed before chemotherapy revealed no axillary metastases. The patient received six courses of intravenous PTX (175 mg/m2 on day 1, every 3 weeks) and intravenous CBDCA (AUC6 on day 1, every 3 weeks) as combination therapy. Abdominal lymph node dissection was performed between chemotherapy courses 3 and 4. The lump in the left breast showed partial clinical response, and partial resection of the left breast was performed after completion of chemotherapy. In Japan, few cases of primary breast cancer treated preoperatively using carboplatin-containing regimens have been described.

The role of surgery in patients with advanced gynaecological cancers participating in phase I clinical trials

OBJECTIVE

While gynaecological cancer patients who participate in Phase I clinical trials are not routinely considered for elective surgery because of a short life expectancy, this should not be overlooked in carefully selected responding patients.

METHODS/RESULTS

We describe two cases of patients with different gynaecological cancers, who received treatment within separate phase I trials, and who then proceeded to surgical resection of their cancers, resulting in complete remission.

CONCLUSION

Surgery, when feasible, should be taken into consideration as a potential management option, even when patients are receiving treatment within a phase I trial.

Endocrine effects of the tyrosine kinase inhibitor vandetanib in patients treated for thyroid cancer

PURPOSE

The purpose of the study was to assess the endocrine effects of vandetanib, a multikinase inhibitor targeting RET, vascular endothelial growth factor receptor, and epidermal growth factor receptor, in 39 patients with progressive thyroid cancer included in two randomized placebo-controlled trials using vandetanib 300 mg/d.

METHODS

Endocrine samplings were performed at baseline and then every 6 months. We compared differences in endocrine parameters between baseline and on vandetanib therapy or placebo.

RESULTS

During vandetanib treatment, several changes were observed. 1) Calcium (P = 0.0004) and vitamin D (P = 0.001) mean replacement doses were increased; calcium level remained unchanged, but serum 25(OH) vitamin D level decreased (P = 0.001); and serum PTH (P = 0.01) and 1,25(OH)(2) vitamin D (P = 0.01) levels increased, suggesting a decreased intestinal absorption of vitamin D or lack of sun exposure as a result of photosensitization. 2) l-T(4) doses were increased (P < 0.0001) to maintain serum TSH within the normal range. 3) In male patients, total testosterone (P = 0.048), bioavailable testosterone (P = 0.03), and SHBG (P = 0.02) levels increased. Serum inhibin B decreased (P = 0.02) and stimulated FSH increased (P = 0.006), suggesting a Sertoli cells insufficiency. 4) Cortisol level increased (P = 0.007) as well as ACTH level (P = 0.03) and cortisol-binding globulin (P = 0.02), but free urinary cortisol levels remained in the normal range. None of these changes were observed in patients randomized to the placebo arm.

CONCLUSION

In patients with locally advanced or metastatic thyroid cancer, the tyrosine kinase inhibitor vandetanib has several endocrine effects. Thyroid hormone, calcium, and vitamin D analog requirements increased, but consequences of the biological alterations on phosphocalcic metabolism and gonadotrope and adrenal functions are unknown.

Impact of pregnancy on outcome and prognosis of survivors of papillary thyroid cancer

BACKGROUND

Papillary thyroid cancer (PTC) commonly affects women of child-bearing age. During normal pregnancy, several factors may have a stimulatory effect on normal and nodular thyroid growth. The aim of the study was to determine whether pregnancy in thyroid-cancer survivors poses a risk of progression or recurrence of the disease.

METHODS

The files of 63 consecutive women who were followed at the Endocrine Institute for PTC in 1992-2009 and had given birth at least once after receiving treatment were reviewed for clinical, biochemical, and imaging data. Thyroglobulin levels and neck ultrasound findings were compared before and after pregnancy. Demographic and disease-related characteristics and levels of thyroid-stimulating hormone (TSH) during pregnancy were correlated with disease persistence before conception and disease progression during pregnancy using Pearson's analysis.

RESULTS

Mean time to the first delivery after completion of thyroid-cancer treatment was 5.08 ± 4.39 years; mean duration of follow up after the first delivery was 4.84 ± 3.80 years. Twenty-three women had more than one pregnancy, for a total of 90 births. Six women had evidence of thyroid cancer progression during the first pregnancy; one of them also showed disease progression during a second pregnancy. Another two patients had evidence of disease progression only during their second pregnancy. Mean TSH level during pregnancy was 2.65 ± 4.14 mIU/L. There was no correlation of disease progression during pregnancy with pathological staging, interval from diagnosis to pregnancy, TSH level during pregnancy, or thyroglobulin level before conception. There was a positive correlation of cancer progression with persistence of thyroid cancer before pregnancy and before total I-131 dose was administered.

CONCLUSIONS

Pregnancy does not cause thyroid cancer recurrence in PTC survivors who have no structural or biochemical evidence of disease persistence at the time of conception. However, in the presence of such evidence, disease progression may occur during pregnancy, yet not necessarily as a consequence of pregnancy. The finding that a nonsuppressed TSH level during pregnancy does not stimulate disease progression suggests that it may be an acceptable therapeutic goal in this setting.

Papillary microcarcinoma of the thyroid among atomic bomb survivors: tumor characteristics and radiation risk

BACKGROUND

: Radiation exposure is an established cause of clinical thyroid cancer, but little is known about radiation effects on papillary microcarcinoma (PMC) of the thyroid, a relatively common subclinical thyroid malignancy. Because the incidence of these small thyroid cancers has been increasing, it is important to better understand them and their relation to radiation.

METHODS

: PMCs were identified in a subset of 7659 members of the Life Span Study of atomic bomb survivors who had archived autopsy or surgical materials. We conducted a pathology review of these specimens and evaluated the histological features of the tumors and the association between PMCs and thyroid radiation dose.

RESULTS

: From 1958 to 1995, 458 PMCs were detected among 313 study subjects. The majority of cancers exhibited pathologic features of papillary thyroid cancers. Overall, 81% of the PMCs were of the sclerosing variant and 91% were nonencapsulated, psammoma bodies that occurred in 13% and calcification was observed in 23%. Over 95% had papillary or papillary-follicular architecture and most displayed nuclear overlap, clear nuclei, and nuclear grooves. Several of these features increased with increasing tumor size, but no association was found with radiation dose. A significant radiation-dose response was found for the prevalence of PMCs (estimated excess odds ratio/Gy = 0.57; 95% confidence interval, 0.01-1.55), with the excess risk observed primarily among women.

CONCLUSIONS

: Exposure to low-to-moderate doses of ionizing radiation appears to increase the risk of thyroid PMCs, even when exposure occurs during adulthood. Cancer 2010. (c) 2010 American Cancer Society.

Phase II study of liposomal cisplatin (SPI-77) in platinum-sensitive recurrences of ovarian cancer

BACKGROUND

Cisplatin is a highly effective chemotherapeutic agent against epithelial ovarian cancer but is associated with significant toxicities. SPI-77 is a liposomal pegylated formulation of cisplatin that was developed to reduce systemic toxicity and to better deliver cisplatin to tumors. We assessed the response rates and safety of SPI-77, in patients with recurrent epithelial ovarian cancer.

PATIENTS AND METHODS

Patients were selected for having previously achieved a platinum treatment free interval of greater than 6 months (e.g. platinum-sensitive) and high potential of achieving responses when rechallenged with a platinum drug. SPI-77 was administered at a dose of 260 mg/m(2) every 21 days until disease progression.

RESULTS

Enrollment was terminated after 5 patients were treated because of concern with the adequacy of the formulation. Four out of the five patients had stable disease as best response. While no serious, unexpected adverse events occurred in spite of large cumulative doses of SPI-77, there were concerns related to the large lipid load and prolonged persistence of residual platinum in body stores.

CONCLUSION

The results of this study, although inconclusive regarding its primary endpoints, provide some important lessons for the development of similar liposomal platinum agents.

Suppressive effect of sulindac on branch duct-intraductal papillary mucinous neoplasms

BACKGROUND

When considering surgery for branch duct-intraductal papillary mucinous neoplasms (BD-IPMNs) with suspected malignancy, it should be recognized that these lesions are frequently multifocal and are usually found in elderly patients with potential comorbidities that could affect the outcome of surgery. Clinical trials of chemoprevention have been conducted for a wide variety of malignancies.

METHODS

Twenty-two BD-IPMN patients participated in the trial at our institution from June 2004 to January 2007. Ten of the 22 patients who rejected surgical therapy although their lesions or clinical symptoms met the criteria for surgical resection of the International Association of Pancreatology guidelines were assigned to the treatment group. Sulindac (150 mg twice daily) and omeprazole (20 mg once daily) were administered to these patients for 18 months. The remaining 12 patients comprised the control group. Branch duct diameter and mural nodule heights were monitored by either magnetic resonance cholangiopancreatography (MRCP) or computed tomography (CT) and by endoscopic ultrasonography (EUS).

RESULTS

Both branch duct diameter and mural nodule height of BD-IPMNs in the treatment group were significantly reduced, while those in the control group were unchanged. Immunohistochemical staining for cyclooxygenase-1 and -2 was negative in hyperplasia, adenoma and carcinoma portions of resected pancreatic specimens but was clearly positive for glutathione-S-transferase pi (GST-pi), suggesting that GST-pi is a putative target molecule for sulindac.

CONCLUSIONS

Although a larger scale randomized controlled study is needed in future, the present results suggest the promise of chemoprevention of carcinoma derived from BD-IPMNs by sulindac.

[A case of peritoneal serous papillary adenocarcinoma]

A78-year-old female was admitted to our hospital with anorexia due to ascites. We were not able to diagnose by cytological diagnosis. For a definite diagnosis she underwent an open biopsy. Histological findings revealed observable papillary adenocarcinoma with psammoma body, carcinoma cells were positive for Ber-EP4 on immunostaining, and ovaries were normal. Thus, we made a diagnosis of peritoneal serous papillary adenocarcinoma. She was treated by intraperitoneal administration of CDDP(20 mg/day: day 1, every four weeks). Ascites vanished and CA125 was within the normal range. There was no recurrence after 3 years, but Virchow's lymph node metastasis occurred. The patient is still alive 12 months after metastasis with CDDP intraperitoneal administration.

Favorable effects of long-term therapy with gonadoliberin analogues in three patients with advanced and recurrent ovarian cancer

BACKGROUND

Numerous scientific reports indicate a high possibility of gonadotrophin involvement in ovarian cancer neoplasia.

CASE PRESENTATION

In a 49-year-old patient with recurrent ovarian cancer, a present survival of ten years has been achieved. She has been using GnRH analogues for nine years. A 32-year-old patient with a primary highly advanced ovarian cancer received standard therapy and additional implants with GnRH analogues as consolidation therapy for 20 months. Overall survival is 14 years. In a 56-year-old patient with advanced ovarian cancer GnRH analogues were used as consolidation therapy for seven years, achieving seven years of a complete clinical remission and nine and a half years of survival up to now.

CONCLUSION

It seems that gonadoliberin analogues should find their place in ovarian cancer therapy.

Tolerance and activity of oxaliplatin with protracted topotecan infusion in patients with previously treated ovarian cancer. A phase I study

BACKGROUND

Topotecan 14-day infusion combined with cisplatin was highly active in ovarian cancer, but too myelosuppressive. We therefore sought to evaluate the feasibility of substituting oxaliplatin for cisplatin to improve safety.

METHODS

Ovarian and primary peritoneal cancer patients, pretreated with at least one prior platinum-containing regimen, performance status (PS) 0-1, without prior pelvic radiation were eligible. Topotecan was continuously infused days 1-15; oxaliplatin was given days 1 and 15; cycles were repeated every 28 days. Five dose levels were explored: topotecan (mg/m2/day)/oxaliplatin (mg/m2) doses: (1) 0.2/65; (2) 0.2/75; (3) 0.2/85; (4) 0.3/85; (5) 0.4/85.

RESULTS

Twenty-three patients (20 ovarian, 1 tubal, and 2 peritoneal) were entered: median age 56 years (range, 37-77); PS: 0=12 and 1=11; histology: papillary serous 7, serous 4, adenocarcinoma 8, poorly differentiated 2. Median of 4 cycles were delivered. Grade 3 neutropenia occurred in 3 of 7 patients at level 5 (with fever at levels 4 and 5), without grade 4 neutropenia or thrombocytopenia. Other toxicities were mild and reversible (mainly gastrointestinal), except one grade 3 neuropathy and one oxaliplatin-related grade 3 hypersensitivity reaction. Six objective responses (five of them complete) were documented among 22 patients spanning several dose levels.

CONCLUSION

Topotecan continuous infusion, combined with oxaliplatin, was associated with no grade 4 hematologic toxicity and evidence of activity. The recommended phase II dose is topotecan 0.4 mg/m2/day continuous infusion d1-15 with oxaliplatin 85 mg/m2 on days 1 and 15. A phase II evaluation as second-line treatment for both platinum-sensitive and -resistant ovarian cancer recurrences is ongoing.

Weekly paclitaxel/5-fluorouracil followed by platinum retreatment for patients with recurrent ovarian cancer: a single institution experience

PURPOSE

Since the prognosis of recurrent ovarian cancer patients is still poor, we need to establish a useful treatment strategy to achieve their long-term survival. We treated recurrent ovarian cancer patients with weekly paclitaxel (PTX)/5-fluorouracil (5-FU) followed by platinum retreatment to investigate its clinical efficacy in a preliminary manner.

METHODS

Sixteen patients with recurrent ovarian cancer, pretreated with taxane and platinum, were treated with weekly paclitaxel (PTX)/5-fluorouracil (FU). PTX (80 mg/m2) on day 1, 8, and 15 was combined with a bolus injection of 5-FU (500 mg/m2) on day 2, 9, and 16. Chemotherapy was given every four weeks. Patients with stable disease or progressive disease were subsequently retreated with a platinum-containing regimen. Response was evaluated by RECIST criteria or CA125 criteria. Toxicities were evaluated according to the National Cancer Institute-common toxicity criteria (NCI-CTC) version 3.

RESULTS

Among five patients with sensitive disease, one of four patients with measurable tumor and one without measurable tumor responded to weekly PTX/5-FU. Among 11 patients with resistant disease, none of five patients with measurable tumor and three of six patients without measurable tumor responded to weekly PTX/5-FU. Overall objective response rate by weekly PTX/5-FU was 31.3% (5/16). Among 16 patients, 13 patients who showed no response or progressive disease (three with sensitive disease, ten with resistant disease) received platinum retreatment after weekly PTX/5FU. All three patients with sensitive disease and three of ten patients with resistant disease revealed response to platinum retreatment. Overall objective response rate by platinum retreatment after weekly PTX/5-FU was 46.2% (6/13).

CONCLUSIONS

Weekly PTX/5FU followed by platinum retreatment could be a useful treatment strategy for recurrent ovarian cancer patients. We need to establish the standard treatment strategy for recurrent ovarian cancer patients with a poor prognosis.

[Lung adenocarcinoma feigning an interstitial lung disease in a 30-year-old man]

A case of a 30-year-old man is presented. He had a past medical history of asthma and presented with cough, shortness of breath, fever and chest pain. The chest X-ray showed cardiomegaly and a interstitial pattern. The echocardiogram revealed a severe pericardial effusion that required performing a pericardiocentesis. A CT scan showed mediastinal adenopathies and reticulonodular interstitial pattern. A bronchoscopy could not be completed because of non-tolerance. Finally a lung biopsy allowed us to reach a final diagnosis of lung adenocarcinoma. Following, some aspects of lung cancer in young people are commented, especially its incidence, histology, symptoms and a prognosis. A few aspects of the interstitial lung disease are also addressed and the differential diagnosis with lymphangitic carcinomatosis.

Advances in the medical management of differentiated thyroid carcinoma and their impact on the surgical approach

The introduction of recombinant human TSH and neck ultrasonography has refined the management of differentiated thyroid cancer, leading to the publication of new guidelines by the American Thyroid Association (ATA) and a consensus report by the European Thyroid Association (ETA) in 2006. In this paper, we give an overview of the current medical management of differentiated thyroid cancer (pre-surgical, post-surgical), of how the advances have been integrated into the recent 2006 ATA guidelines and ETA consensus and finally, of the impact on the surgical management (first surgery, treatment of cervical lymph nodes) of differentiated thyroid cancer.

[Two lung adenocarcinoma patients with multiple brain metastasis treated with Gefitinib and surviving more than 2 years]

Case 1 is a 78-year-old woman in whom lung adenocarcinoma with multiple brain metastasis (cT2N3M1, stage IV) was diagnosed. She was treated with Gefitinib alone. Her lung tumor and metastatic brain lesions decreased 6 months after the start of therapy. She has no recurrence and is still alive with a good performance status after 25 months. Case 2 is an 80-year-old woman in whom lung adenocarcinoma with multiple brain (cT2N3M1, stage IV) was diagnosed. She was also treated with Gefitinib alone and her lung tumor and metastatic brain becomes improved 6 months after the start of therapy. She maintained a good performance status for more than 2 years (29 months). However, 29 months after beginning treatment, she had recurrence in bone and died 2 months later, 31 months after the start of therapy. The prognosis of non-small cell lung cancer with multiple brain metastasis is very poor and the efficacy of chemotherapy for the treatment of multiple brain metastases is limited, and longterm survival remains disappointing. We report two lung adenocarcinoma patients with multiple brain metastasis who survived more than 2 years by treatment with Gefitinib alone.

Metastasis to sigmoid colon mucosa and submucosa from serous borderline ovarian tumor: response to hormone therapy

Distant metastasis to sites other than lymph nodes of borderline ovarian tumor is rare. We describe a case metastasized to sigmoid colon mucosa and submucosa. The metastatic lesion was detected incidentally by screening colonoscopy 7 years after the patient was treated for the primary tumor. The metastatic lesion responded well to treatment with oral Arimidex 1 mg/day. A follow-up colonoscopy with biopsy and imaging studies after 3 months of treatment revealed no evidence of disease in the sigmoid colon. This case showed that the sigmoid colon mucosa and submucosa should be considered as one of distant metastatic sites of a serous borderline ovarian tumor and the favorable response to Arimidex provides support the use of hormone therapy in women with serous borderline ovarian tumor.

[Case of leptomeningeal carcinomatosis effectively treated with intrathecal chemotherapy using ventriculoperitoneal shunt]

A 70-year-old man presented with dizziness, headache and hearing loss. He was admitted to our hospital because of increasing unsteadiness of gait. Magnetic resonance imaging of the brain revealed meningeal thickening with enhancement. The lumbar puncture revealed high opening pressure. The cerebrospinal fluid showed pleocytosis, high carcinoembryonic antigen (CEA) concentration, and presence of neoplastic cells, leading to the diagnosis of leptomeningeal carcinomatosis. Systemic investigation for primary neoplasm identified a Bormman type 3 gastric cancer (papillary adenocarcinoma with micropapillary pattern). Except for the meninges, no metastatic lesions could be detected. A ventriculoperitoneal shunt (Codman Hakim Programmable Valve) was placed for management of intracranial hypertension and intrathecal chemotheray. He was started on oral S-1 (TS-1) combined with intrathecal methotrexate injection using the VP shunt reservoir. In two weeks, headache and hearing loss completely disappeared and gait disturbances started to improve. CSF findings also improved remarkably with disappearance of neoplastic cells and almost normalization of CEA. For the next five months, he was well on oral S-1 and monthly intrathecal chemotherapy, being able to walk using a walker and to stay at home. He subsequently developed posterior cortical symptoms such as prosopagnosia and cortical blindness and gradually lapsed into coma. He died from pneumonia one year after the onset of neurological symptoms. At autopsy, primary gastric cancer was found but much reduced in size. No peritoneal metastasis could be found. In the brain, leptomeningeal carcinomatosis involved the occipital lobes, the base of the temporal lobe, and the cerebellum. We suggest that intrathecal chemotherapy using ventriculoperitoneal shunt with programmable valve system could be an effective method for the treatment of meningeal carcinomatosis.

[A case of unresectable non-small cell lung cancer with pleural dissemination successfully treated with DIF]

A 68-year-old woman was referred to our hospital with an abnormal shadow on her chest CT, which showed a mass lesion 3.5 cm in diameter at segment 7 in the right lung. At thoracotomy, a curative operation could not be performed because of pleural dissemination, so a partial resection was done for the histopathological examination. It showed papillary adenocarcinoma and clinical Stage IIIB. Her family hoped not to inform her that a curative operation was impossible. We explained the necessity of adjuvant chemotherapy to her, and she consented to UFT. However, the level of CEA gradually elevated, and pleural effusion on the right side appeared 2 years after operation. We converted UFT into TS-1. The level of CEA gradually reduced, and pleural effusion disappeared. We conclude that oral administration of UFT or TS-1 is useful as palliative chemotherapy for advanced non-small cell lung cancer without serious adverse events and worsening of quality of life.

[A case of complete response in a primary lesion treated by gefitinib for two years after surgery of brain metastasis from lung cancer]

A 54-year-old woman was admitted to our hospital for vertigo, headache and vomiting at the end of July, 2001. Under a diagnosis of cerebellar tumor and right lung tumor, she underwent a resection of cerebellar tumor on August 7, 2001. The histopathological diagnosis was "metastatic adenocarcinoma". Lung cancer was doubted as for the origin, however, she did not want further examination. The patient was given 2 courses of postoperative chemotherapy (CBDCA+VNR) and radiotherapy (50 Gy), and discharged. Gefitinib treatment was begun in September, 2002 at her request. The tumor marker was not elevated, and the tumor size on CT showed the tendency toward some reduction. Close examination including PET revealed no metastasis. The patient then underwent right upper lobectomy (ND 2 a) on October 8, 2004 at her request. Histopathologically, psammoma body existed but no cancer cells nor lymph node metastasis. It seemed that there was a complete response by gefitinib after 3 years.

Treatment of uterine papillary serous carcinoma with platinum-based chemotherapy and paclitaxel

Uterine papillary serous carcinoma (UPSC) is more aggressive than endometrioid endometrial cancer, as it often presents with advanced disease and follows a pattern of spread that resembles the serous carcinoma of the ovary. There exists little data on evaluating the combination of carboplatin and paclitaxel in UPSC. Institutional Review Board permission was obtained for a retrospective review. Tumor registry search was used to identify all patients with UPSC from 1990 to 2003. Charts were retrospectively evaluated from patients who had received at least three cycles of carboplatin and paclitaxel as first-line chemotherapy. Only patients with histologically confirmed UPSC who were treated first line with carboplatin/paclitaxel chemotherapy were included. Nineteen patients with UPSC were identified, who were treated with carboplatin and paclitaxel in the first-line adjuvant setting after initial surgical cytoreduction. All patients received at least three cycles, with 12 of the 19 patients receiving six cycles. Five patients were treated with consolidation radiotherapy following first-line chemotherapy. Mean age was 69 years (range 55-88). The majority of patients had stage III disease (n= 11). Mean follow-up for the group was 29.5 months (7-76 months). A median progression-free interval of 12 months was seen across the entire cohort. Fourteen patients achieved a complete response following chemotherapy. The results of Gynecologic Oncology Group protocol 122 suggest that patients with advanced endometrial cancer have an improved progression-free survival when treated primarily with chemotherapy rather than radiation therapy. The results of our study show a high response rate to paclitaxel/carboplatin outpatient chemotherapy in a group of patients historically believed to have chemoresistant disease. Further prospective study of this regimen is planned.

Pulmonary papillary serous adenocarcinoma with intraperitoneal and ovarian tumors: identification of primary site. A case report

Papillary serous adenocarcinoma has been recognized as a highly malignant ovarian cancer and is also not uncommonly seen in primary lung cancer. Difficulty may exist in determining the origin of the primary tumor in women with synchronous pulmonary and ovarian tumors. We present a patient who was initially diagnosed and treated as stage IV papillary serous ovarian cancer with diffuse pulmonary metastases. Only transient symptomatic improvement was achieved after standard chemotherapy for ovarian cancer, and then she died of respiratory distress during treatment. Poor tumor response to chemotherapy prompted us to reevaluate the previous bronchoscopic biopsy, and immunohistochemical studies, which were cytokeratin (CK) 7 positive, CK20 negative, and thyroid transcription factor-1 (TTF-1)-positive, provided irrefutable evidences for the diagnosis of primary lung cancer. We suggest that in dealing with coexistence of ovarian and pulmonary tumors, immunohistochemical study by using CK7, CK20, and TTF-1 may be helpful in the differentiation of the primary origin.

Photodynamic therapy with topical 5-aminolevulinic acid as a post-operative adjuvant therapy for an incompletely resected primary nasopharyngeal papillary adenocarcinoma: A case report

BACKGROUND AND OBJECTIVES

Surgical excision of primary nasopharyngeal papillary adenocarcinoma is sometimes incomplete with remaining microscopic disease. Post-operative radiotherapy only has limited efficacy but may cause many complications.

STUDY DESIGN/MATERIALS AND METHODS

Photodynamic therapy (PDT) was used as a post-operative adjuvant therapy for an incompletely resected primary nasopharyngeal papillary adenocarcinoma. A special form of 20% topical 5-aminolevulinic acid (5-ALA), which was originally a liquid form and became a gel form after applied on the nasopharynx, was used as the photosensitizer. A 2-mm optic fiber delivered the light (633 nm wavelength) to the lesion with a fluence rate of 100 mW/cm2 generated by a diode laser under 5 mm 0 degrees endoscope assistance. The total energy delivered was 150 joules/cm2.

RESULTS

No significant acute side effect was noted and the nasopharyngeal wound healed rapidly. The patient is alive without locoregional recurrence or distant metastasis for 5 years. Articulation, salivation, and swallowing functions are all well preserved.

CONCLUSION

Post-operative adjuvant PDT can successfully cure an otherwise difficult to treat disease with preservation of good life quality of the patient. Potential complications of PDT (e.g., photosensitivity) can be prevented by a special formulation of topical 5-ALA preparation.

Villoglandular papillary adenocarcinoma of the uterine cervix responding to neoadjuvant chemotherapy with docetaxel and cisplatin: a case report

Villoglandular papillary adenocarcinoma (VGPA) of the uterine cervix is a rare neoplasm, and its treatment has rarely been reported. We report a patient with VGPA stage IIA responding to neoadjuvant chemotherapy with docetaxel (60 mg/m2 as an intravenous infusion) and cisplatin (70 mg/m2 as an intra-arterial infusion). At 3 weeks after completing one course of this regimen, the tumor size was reduced from 5.3 x 4.0 cm to 2.0 x 2.0 cm (81.1% reduction), revealed by computed tomography. Accordingly, the patient underwent radical hysterectomy, and there have been no signs of recurrence. Thus, the combination of docetaxel and cisplatin is suggested to be useful for neoadjuvant chemotherapy of cervical adenocarcinoma.

Phase II trial of docetaxel in advanced or metastatic endometrial cancer: a Japanese Cooperative Study

The purpose of this study was to determine whether docetaxel has antitumour activity in patients with advanced or recurrent endometrial carcinoma. Chemotherapy-naïve or previously treated patients (one regimen) with histopathologically documented endometrial carcinoma and Eastern Cooperative Oncology Group performance status ⩽2 entered the study. Docetaxel 70 mg m⁻² was administered intravenously on day 1 of a 3-week cycle up to a maximum of six cycles. If patients responded well to docetaxel, additional cycles were administered until progressive disease or unacceptable toxicity occurred. Of 33 patients with a median age of 59 years (range, 39–74 years) who entered the study, 14 patients (42%) had received one prior chemotherapy regimen. In all, 32 patients were evaluable for efficacy, yielding an overall response rate of 31% (95% confidence interval, 16.1–50.0%); complete response and partial response (PR) were 3 and 28%, respectively. Of 13 pretreated patients, three (23%) had a PR. The median duration of response was 1.8 months. The median time to progression was 3.9 months. The predominant toxicity was grade 3–4 neutropenia, occurring in 94% of the patients, although febrile neutropenia arose in 9% of the patients. Oedema was mild and infrequent. Docetaxel has antitumour activity in patients with advanced or recurrent endometrial carcinoma, including those previously treated with chemotherapy; however, the effect was transient and accompanied by pronounced neutropenia in most patients.

[Aortic replacement during post chemotherapy retroperitoneal residual tumor resection for nonseminomatous germ cell tumor: a case report]

A 59-year-old man visited our hospital complaining of epigastralgia. A large hard mass was palpable in the abdominal cavity. Abdominal computed tomography revealed large retroperitoneal cystic tumors. His left testis was hard and swollen. Under the diagnosis of testicular tumor and retroperitoneal lymph node metastasis, left radical orchiectomy was performed and the histopathological examination showed mature teratoma. He was diagnosed with nonseminomatous germ cell tumor and retroperitoneal lymph node metastasis (TNM classification stage IIC). He received three cycles of chemotherapy with bleomycin, etoposide, and cisplatin and we performed retroperitoneal residual tumor resection. Because the tumor tightly adhered to the aortic wall, abdominal aorta was resected and replaced by an artificial vessel. The post-operative course was uneventful. Histopathological diagnosis was cystopapillary adenocarcinoma and mature teratoma. The patient is well 1 and a half years after the operation without recurrence.

Weekly paclitaxel in patients with CAP-resistant advanced or recurrent endometrial carcinoma: a series of four patients

We evaluated the feasibility of weekly paclitaxel in patients with recurrent or advanced endometrial carcinoma who had failed treatment with cyclophosphamide, doxorubicin, and cisplatin (CAP). We treated four patients with CAP-resistant recurrent or advanced endometrial carcinoma with paclitaxel. Paclitaxel (80 mg/m(2); infused over 1 h) was administered weekly for a maximum of 18 weeks, unless disease progression or intractable toxicity developed. A complete response was observed in one patient and a partial response in two patients. Disease progression was found in one patient. Two patients developed grade 3 leukopenia or neutropenia. Neurotoxicity for all patients was within grade 1. Outpatient treatment with weekly paclitaxel was well-tolerated and feasible for patients with CAP-resistant recurrent or advanced endometrial carcinoma. Further trials to confirm the efficacy and toxicity of weekly paclitaxel are warranted.

[A case with advanced carcinoma of the gallbladder responding to UFT monotherapy]

Gallbladder carcinoma is a fatal disease with highly metastatic potential, and the chemotherapeutic regimen has not been established yet. We reported here a case of gallbladder carcinoma with lung and liver meatstases responding to a single agent, UFT. A 70-year-old female with advanced carcinoma of the gallbladder and bilateral pulmonary metastases were treated with UFT 600 mg/day weekday for half a year. Pulmonary metastases disappeared completely, and the primary lesion shrank markedly 6 months after. Unfortunately, the patient died 1.5 years after the start of treatment due to relapse of liver and lung lesions.

A huge primary peritoneal papillary adenocarcinoma which demonstrated imaging findings similar to those of extrahepatic-growing type hepatic tumor: report of a case

We herein report a 69-year-old woman who presented with a huge intra-abdominal tumor which demonstrated imaging findings similar to those of extrahepatic-growing type hepatic tumor, but turned out to be primary peritoneal papillary adenocarcinoma. Computed tomography showed a well-demarcated mass, measuring 12.0 cm in diameter, which came in contact with the lateral segment of the liver and invaded the diaphragm and abdominal wall. Distant lymph node metastasis was also detected. A fine-needle aspiration biopsy of the tumor showed poorly differentiated adenocarcinoma of unknown origin. After chemotherapy with 5-fluorouracil and cisplatin, the maximal diameter of the tumor decreased to 6.0 cm. The patient then underwent a tumorectomy together with a lateral segmentectomy of the liver, a splenectomy, a partial resection of the diaphragm and abdominal wall, and a left oophorectomy. Histological and immunohistochemical examinations demonstrated the tumor to be primary peritoneal papillary adenocarcinoma.

Preliminary experience with salvage weekly paclitaxel in women with advanced recurrent ovarian carcinoma

PURPOSE OF INVESTIGATION

To assess the role of palliative chemotherapy with weekly paclitaxel in patients with recurrent ovarian cancer.

METHODS

Thirty-two patients with paclitaxel- and platinum-resistant ovarian cancer were treated with weekly paclitaxel at 80 mg/m2 as a 1-hour intravenous infusion weekly for six weeks every eight weeks (1 cycle). This schedule was considered to be given for three cycles. Evaluation of radiographically measurable disease was used in the assessment of response. CA-125 was used to classify responses only in the absence of a measurable lesion.

RESULTS

Thirty-two patients were all assessable for response. Of these, nine patients (28.1%) achieved a partial response and one patient achieved a complete response, leading to an overall response rate of 31.2%. Stable disease occurred in six patients (18.8%), and 16 patients (50%) had progressive disease. Nine patients died of progressive disease while on treatment. The median survival for the entire group was 10.5 months (range 2.5-22 months). Grade 3 or 4 leukopenia and neutropenia occurred in eight and six patients, respectively. Four of these patients developed febrile neutropenia without infection. Grade 1 and 2 peripheral neuropathies were observed in 50% of the patients without causing any premature drop out. Severe (grade 3 or 4) peripheral neuropathy was not observed. There were 11 patients with grade 1 or 2 myalgias.

CONCLUSION

Weekly paclitaxel regimen is well tolerated with acceptable toxicity. The favorable toxicity profile and the encouraging antitumor activity observed in this study makes this regimen an option for the salvage treatment of patients with recurrent ovarian cancer.

[Urachal carcinoma treated with neoadjuvant intra-arterial chemotherapy: a case report]

A 43-year-old man visited our clinic with gross hematuria. Ultrasonography and computed tomography demonstrated a tumor at the bladder dome. Cold punch biopsy revealed well-differentiated adenocarcinoma and stage III A urachal carcinoma was diagnosed. Neoadjuvant intra-arterial chemotherapy with cisplatin, adriamycin and angiotensin II was performed and 40% reduction of tumor size was noted 3 weeks after this therapy. En bloc segmental resection was performed. Augmentation ilealcystoplasty was subsequently performed to secure bladder capacity. Adjuvant chemotherapy (UFT) was given for 1 year. Cystolithotomy and closure of ventral hernia were required 10 years after radical surgery for postoperative complications. The patient has survived 12 years with no evidence of local recurrence or distant metastasis.

Weekly topotecan in a heavily pretreated patient with peritoneal papillary serous adenocarcinoma

Peritoneal papillary serous adenocarcinoma is a rare müllerian tumor type that is histologically similar to ovarian serous carcinoma. The low incidence of peritoneal papillary serous adenocarcinoma has hindered the establishment of a standard of care for this disease. A 56-year-old woman, who had undergone an abdominal hysterectomy 25 years earlier, presented with a vaginal nodule and palpable pelvic mass. She underwent debulking surgery and was diagnosed with stage IIIC peritoneal papillary serous adenocarcinoma. After 6 cycles of paclitaxel/carboplatin and 10 cycles of liposomal doxorubicin/cyclophosphamide, laparotomy revealed microscopic disease. This heavily pretreated patient then started topotecan therapy (1.0 mg/m(2)/day, x 5 days). After several dosing adjustments because of fatigue and malaise, weekly topotecan 4.0 mg/m(2) was determined to be the best-tolerated dosage. The patient ultimately received 14 weekly cycles of topotecan. After 12 weekly cycles, she achieved a complete response, which was maintained for 25 weeks with weekly topotecan therapy with a subsequent recurrence. Topotecan was reinstated. She maintains a disease-free interval of 58 weeks. Weekly topotecan demonstrated antitumor activity and was well tolerated in a patient with recurrent peritoneal papillary serous adenocarcinoma.

Adjuvant chemotherapy in a unique population of patients with gastric cancer undergoing surgery

BACKGROUND/AIMS

Total gastrectomy with D2 dissection theoretically removes the gross primary tumor with its potential route of dissemination, that is locoregional lymph nodes. Complementary therapy for the control of systemic microscopic disease should be taken into consideration in patients whom surgery with curative intent was performed.

METHODOLOGY

Twenty-eight patients with moderately differentiated, locally advanced gastric carcinoma underwent total gastrectomy with D2 lymph node dissection. The operative mortality rate was 0% in this series. Fifteen patients received six courses of adjuvant 5-FU + leucovorin in doses of 425 mg/m2/d and 20 mg/m2/d respectively in five-day cycles month ly. The remaining 13 patients constituted the control (surgery only) group.

RESULTS

The mean disease-free and overall survival rates were 41 and 48 months (p: 0.78) and 42 and 53 months (p: 0.43) in the control and chemotherapy groups, respectively. The odds ratio for crude mortality was 0.7.

CONCLUSIONS

Although statistical significance has not been achieved in this study, a trend toward adjuvant chemotherapy has emerged in that unique group of patients with moderately differentiated (intestinal type) adenocarcinoma of the stomach undergoing curative surgery.

[A case of effective treatment of oral TS-1 and intravenous MMC administration for multiple metastases of gastric cancer]

A 49-year old man underwent distal gastrectomy (D3) for circumferential type 3 cancer at the gastric antrum and cholecystectomy in September 2002. During the surgery, multiple metastases were observed predominantly in the left lobe of the liver, and lateral segmentectomy was performed as non-curative (curability-C) resection leaving the small metastases in the right lobe of the liver. Based on the results of chemo-sensitivity tests (5-FU 15.0%, CDDP 34.0%, MMC 35.3%, TXT 0.0%), we started to administer TS-1 (100 mg/day for 4 weeks followed by a 2-week rest interval) and MMC (10 mg/body on day 1). Due to leukocytopenia, the regimen was changed to TS-1 (100 mg/day for 4 weeks followed by a 2-week rest interval) and MMC (4 mg/body every other week [day 1, 14]) from the second course. Levels of tumor markers dropped and liver metastatic lesions remarkably decreased in size by CT after the third course. In conclusion, a combination of TS-1/MMC may be regarded as one option for postoperative adjuvant chemotherapy for outpatients.

Prolonged stabilization of platinum/paclitaxel-refractory ovarian cancer with topotecan: a case report and review of the literature

A combination of a paclitaxel and platinum analog is currently the standard first-line chemotherapy for women with ovarian cancer, with response rates of 20-37%. As patients who relapse have a poor prognosis and treatment options are limited, there is an urgent need to develop new agents with novel mechanisms of action for use as a second-line, non-cross-resistant chemotherapy in ovarian cancer. In this report, we describe a patient with platinum/paclitaxel-refractory ovarian cancer who received topotecan and reached long-term stabilization of her disease. The patient was administered 1.5 mg/m2 topotecan for five days in 17 cycles. She was also given granulocyte colony-stimulating factor (G-CSF) support to prevent severe granulocytopenia; no hematologic toxic effect was experienced. Her quality of life was good throughout the treatment, and also her daily activities were unaffected.

Case report: detection of an advanced ovarian malignancy by cervical cytology

There are currently no recommended screening tests for the early detection of ovarian cancer. Ovarian malignancies are most often discovered on bimanual exam at advanced stages, resulting in a high mortality from this disease. While the Papanicolaou (Pap) smear is not a reliable screen for the detection of ovarian cancer, abnormal cytology may be the initial indicator of ovarian malignancy. This is a case report of an invasive serous adenocarcinoma of the ovary that was discovered as the result of a clinical work-up for abnormal cytology reported on a Pap smear.

Preoperative intraarterial infusion chemotherapy for advanced gastric cancer--a retrospective review of four cases

For the purpose of improving operability and curability, we performed intraarterial infusion chemotherapy on four patients with advanced gastric cancer diagnosed pathologically as papillary adenocarcinoma or poorly differentiated adenocarcinoma. Anti-cancer drugs including cis-diamminedichloroplatinum (II), epirubicin, and mitomycin C were administered through catheters whose tips were placed at various sites, as follows: celiac artery, common hepatic artery, right and left gastric artery, accessory left gastric artery, gastroduodenal artery, and right gastroepiploic artery. The therapeutic effect was evaluated by computed tomography (CT) and double contrast X-ray examination of the stomach. A partial response was obtained in one patient, there was no change in two patients, and the fourth patient showed no change and died eight months later. One patient had no recurrence, and recurrence was found in two. The major toxicity was bone marrow suppression, and other side effects such as appetite loss, nausea, and vomiting were all transient. A deep gastric ulcer was found in one patient, but it was cured by intravenous administration of H2 blocker. Although the four patients showed varying responses, intraarterial chemotherapy may prove to be an assistant therapy that enhances the therapeutic effect.

The feasibility and safety of immunotherapy with dendritic cells loaded with CEA mRNA following neoadjuvant chemoradiotherapy and resection of pancreatic cancer

BACKGROUND

Resected pancreatic cancer has a high risk of recurrence and mortality despite the the use of chemoradiotherapy. Because pancreatic cancers express tumor antigens such as carcinoembryonic antigen (CEA), it may be possible to immunize patients to induce tumor antigen-specific immune responses. We hypothesize that high-frequency tumor antigen-specific immune responses will reduce recurrence and increase survival. Autologous dendritic cells (DCs) loaded with tumor antigens are particularly potent at inducing tumor antigen-specific immune responses.

METHODS

Three patients with resected pancreatic adenocarcinoma following neoadjuvant chemoradiotherapy received autologous, monocyte-derived DCs loaded with the mRNA encoding CEA monthly for 6 mo.

RESULTS

It was feasible to generate an adequate number of DC from these patients and to cryopreserve them for repeated use. The DC demonstrated the typical immature phenotype. The immunizations were well-tolerated without evidence of adverse events. All three developed injection site reactivity. All three are alive without evidence of disease at more than 2 1/2 yr from the original diagnosis.

CONCLUSION

The postoperative period following neoadjuvant chemoradiotherapy and pancreaticoduodenectomy for pancreatic cancer is an ideal environment to test novel immune-based therapies. DC-based immunotherapy in this setting is safe and feasible and may lead to prolonged survival.

The use of antioxidants with first-line chemotherapy in two cases of ovarian cancer

OBJECTIVE

Because of poor overall survival in advanced ovarian malignancies, patients often turn to alternative therapies despite controversy surrounding their use. Currently, the majority of cancer patients combine some form of complementary and alternative medicine with conventional therapies. Of these therapies, antioxidants, added to chemotherapy, are a frequent choice.

METHODS

For this preliminary report, two patients with advanced epithelial ovarian cancer were studied. One patient had Stage IIIC papillary serous adenocarcinoma, and the other had Stage IIIC mixed papillary serous and seromucinous adenocarcinoma. Both patients were optimally cytoreduced prior to first-line carboplatinum/paclitaxel chemotherapy. Patient 2 had a delay in initiation of chemotherapy secondary to co-morbid conditions and had evidence for progression of disease prior to institution of therapy. Patient 1 began oral high-dose antioxidant therapy during her first month of therapy. This consisted of oral vitamin C, vitamin E, beta-carotene, coenzyme Q-10 and a multivitamin/mineral complex. In addition to the oral antioxidant therapy, patient 1 added parenteral ascorbic acid at a total dose of 60 grams given twice weekly at the end of her chemotherapy and prior to consolidation paclitaxel chemotherapy. Patient 2 added oral antioxidants just prior to beginning chemotherapy, including vitamin C, beta-carotene, vitamin E, coenzyme Q-10 and a multivitamin/mineral complex. Patient 2 received six cycles of paclitaxel/carboplatinum chemotherapy and refused consolidation chemotherapy despite radiographic evidence of persistent disease. Instead, she elected to add intravenous ascorbic acid at 60 grams twice weekly. Both patients gave written consent for the use of their records in this report.

RESULTS

Patient 1 had normalization of her CA-125 after the first cycle of chemotherapy and has remained normal, almost 3(1/2) years after diagnosis. CT scans of the abdomen and pelvis remain without evidence of recurrence. Patient 2 had normalization of her CA-125 after the first cycle of chemotherapy. After her first round of chemotherapy, the patient was noted to have residual disease in the pelvis. She declined further chemotherapy and added intravenous ascorbic acid. There is no evidence for recurrent disease by physical examination, and her CA-125 has remained normal three years after diagnosis.

CONCLUSION

Antioxidants, when added adjunctively, to first-line chemotherapy, may improve the efficacy of chemotherapy and may prove to be safe. A review of four common antioxidants follows. Because of the positive results found in these two patients, a randomized controlled trial is now underway at the University of Kansas Medical Center evaluating safety and efficacy of antioxidants when added to chemotherapy in newly diagnosed ovarian cancer.

Tumour dosimetry and response in patients with metastatic differentiated thyroid cancer using recombinant human thyrotropin before radioiodine therapy

The development of recombinant human thyrotropin (rhTSH) has given clinicians new options for diagnostic follow-up and treatment of patients with differentiated thyroid cancer (DTC). This paper evaluates the tumour dosimetry and response following -iodine-131 treatment of metastatic thyroid cancer patients after rhTSH stimulation instead of classical hormone withdrawal-induced hypothyroidism. Nineteen consecutive (131)I treatments in 16 patients were performed after rhTSH stimulation. All patients had undergone a near-total thyroidectomy followed by an ablative dosage of (131)I. They all suffered from metastatic or recurrent disease showing tumoral (131)I uptake on previous post-treatment scintigraphy. Dosimetric calculations were performed using (131)I tumour uptake measurements from post-treatment (131)I scintigrams and tumour volume estimations from radiological images. Response was assessed by comparing pre-treatment serum thyroglobulin (Tg) level with the Tg level 3 months post treatment. In 18 out of 19 treatments, uptake of (131)I in metastatic or recurrent lesions was seen. The median tumour radiation dose was 26.3 Gy (range 1.3-368 Gy), and the median effective half-life was 2.7 days (range 0.5-6.5 days). Eleven of 19 treatments (10/16 patients) were evaluable for response after 3 months. (131)I therapy with rhTSH resulted in a biochemical partial response in 3/11 or 27% of treatments (two patients), biochemical stable disease in 2/11 or 18% of treatments and biochemical progressive disease in 6/11 or 55% of treatments. Our study showed that although tumour doses in DTC patients treated with (131)I after rhTSH were highly variable, 45% of treatments led to disease stabilisation or partial remission when using rhTSH in conjunction with (131)I therapy, without serious side-effects and with minimal impact on quality of life. RhTSH is therefore adequately satisfactory as an adjuvant tool in therapeutic settings and is especially suitable in advanced recurrent or metastatic DTC patients who may be intolerant to TSH stimulation by levothyroxine withdrawal.

ATP-binding cassette superfamily transporter gene expression in human primary ovarian carcinoma

PURPOSE

The purpose of this study is to attempt to characterize patients with unfavorable clinical outcome by the relative mRNA levels of ABC transporter expression in their tumor samples and to examine whether relative mRNA levels of each of the ABC transporters can be a useful predictor of progression-free survival in advanced ovarian carcinoma.

EXPERIMENTAL DESIGN

We examined tumor samples taken from 30 patients with primary serous papillary adenocarcinoma of the ovary for the expression of MDR1 and MRP1, MRP2, and MRP3 mRNA by using real-time reverse transcription-PCR, and we evaluated its correlation with clinical outcome. All 30 patients were divided into three groups according to clinical outcome after debulking surgery and platinum-based chemotherapy: 8 patients were classified into the unfavorable group; 11 were classified into the favorable group; and 11 were classified into intermediate group.

RESULTS

The relative mRNA levels of MRP1 and MRP3 were significantly different among the three groups, and the mRNA levels of MRP1 and MRP3 in the unfavorable group were significantly higher than those in the favorable group by multiple comparison. The relative mRNA levels of MRP1 expression were significantly correlated with those of MRP3 expression. In the 30 patients with serous papillary adenocarcinoma, univariate and multivariate analysis demonstrated that the high relative mRNA levels of MRP1 expression were significantly correlated with a short period of progression-free survival.

CONCLUSIONS

In patients with advanced ovarian serous papillary adenocarcinoma, these results suggest that patients with an unfavorable clinical outcome are characterized by increased levels of coordinated MRP1 and MRP3 mRNA expression in their tumor samples. Furthermore, a higher level of MRP1 mRNA expression can be a candidate for a useful predictor of a shorter period of progression-free survival.

Immunohistochemical confirmation of pulmonary papillary adenocarcinoma metastatic to ovaries

Metastatic papillary adenocarcinomas of the ovary are rare compared to primary ovarian papillary serous carcinomas. We report a case of pulmonary papillary adenocarcinoma metastatic to the ovary and show how this tumor can be differentiated immunohistochemically from an ovarian primary. Paraffin blocks of the ovarian tumor were analyzed for carcinoembryonic antigen, CA 125, surfactant, E-cadherin, N-cadherin, and vimentin. These markers are useful in differentiating epithelial tumors of lung versus ovarian origin. The papillary tumor showed expression of carcinoembryonic antigen, surfactant, and E-cadherin, but was negative for CA 125, N-cadherin, and vimentin. These findings support a lung carcinoma metastatic to the ovary.

Cachexia in patients with advanced cancer

Cancer cachexia generally is considered to be the end stage in the progression of nutritional deterioration and wasting of malignancy (Ottery, 1995). In patients with advanced cancer, this condition is very common and decreases quality of life, as well as survival (Fearon et al., 2001; Ottery; Smith & Souba, 2001; Whitman, 2000). However, if early diagnosis and intervention can control cachexia, the potential exists to greatly improve a patient's quality of life and prolong survival. Because metabolic alterations inhibit the effective use of conventional nutritional support, anti-inflammatory agents or fish oil are possible options. Orexigenic agents may be prescribed if patients wish to improve oral intake. Steroids and progestational agents may be used to attempt to improve mood and appetite. Nutrition affects symptoms that need to be managed effectively. Nurses should work aggressively to correct factors that contribute to decreased food intake (e.g., nausea, pain) and correct factors that worsen debility (e.g., anemia). Information must be presented so that informed choices can be made and realistic eating goals set. An interdisciplinary approach that involves the nurse, physician, dietician, and possibly social worker or case manager, as well as the patient and family, is necessary to identify nutritional alterations, assess specific needs, and plan individual interventions. Whitman (2000) stated that counseling is the most effective and least expensive intervention. It may be conducted by any member of the healthcare team and should be combined with other interventions. Palliation of cachexia in patients with advanced cancer is a challenge for nurses. Hopefully, early and judicious use of these interventions may decrease the significant morbidity and mortality that result from cancer cachexia.

[A case report of advanced gastric cancer responding to TS-1, a novel oral fluorouracil derivative]

TS-1 is a new, oral anticancer agent composed of two modulators, gimeracil (CDHP) and oteracil potassium (Oxo) are mixed with tegafur in a ratio of 1:0.4:1. We report one case of advanced gastric cancer with lung and lymph node metastases that completely responded to TS-1. A 71-year-old woman was admitted to our hospital because of breathlessness. A diagnosis of advanced gastric cancer with extensive lymph node metastases and multiple pulmonary metastases was made. One hundred mg/body/day of TS-1 was orally administrated for 4 weeks. A partial response (PR) was obtained after the first course with regression of multiple pulmonary metastases. After 1 drug-free week, the second course was administered with 120 mg/body/day of TS-1 for 4 weeks. After two courses, the primary tumor was reduced to an ulcer scar with pathological confirmation of a complete disappearance of the cancer tissue. Moreover, computed tomography (CT) showed a complete regression of the extensive lymph node and diffuse lung metastases, for a complete response (CR). The serum level of CEA was reduced from 172.7 ng/ml to 8.1 ng/ml after TS-1 treatment. As for adverse events, only pigmentation of the skin and Grade 2 oral aphta were observed.