Effect of manganese preconditioning and replacing inorganic manganese with organic manganese on performance of male broiler chicks

The effects of manganese (Mn) preconditioning, 96 h post-hatch followed by the replacement of inorganic Mn with different levels of organic Mn (5 to 21 D), on growth, tissue excreta Mn content, gene expression, and enzyme activity were evaluated. A total of 420 day-old male Cobb 500 broilers were divided into 2 groups. One group was fed a corn-soybean meal basal diet containing 17 mg of Mn/kg (preconditioning diet, MnPD); the second group was fed the non-preconditioning diet (NPCD), which was the MnPD supplemented with 60 mg of Mn/kg from manganese sulfate (MnSO4). On day 5, each group was divided into 5 subgroups and were randomly assigned to dietary treatments consisting of MnPD alone or MnPD supplemented with 12 or 60 mg Mn/kg Mn as MnSO4 or Mn proteinate (6 replicate cages of 6 birds). Broiler chicks that were fed the MnPD had lower (P ≤ 0.05) body weight gain (BWG) and G:F ratio when compared to those that were fed the NPCD for 4 D. Birds that were fed MnPD (1 to 4 D) and switched to MnPD supplemented with 60 mg/kg Mn (5 to 21 D) had lower (P ≤ 0.05) BWG compared to those that were fed NPCD (1 to 4 D) and switched to MnPD supplemented with 60 mg/kg Mn for 21 D. Excreta, tibia ash, liver, and heart Mn levels were increased (P ≤ 0.05) by supplemental Mn. The expression of jejunum divalent metal transporter-1 mRNA levels, as well as activities of plasma total super oxide dismutase and liver alanine transaminase, was not affected by MnPD or Mn source and levels. These results confirmed that feeding marginally deficient Mn diets to broiler chicks post-hatch does affect growth rate and tissue Mn concentration.

Effect of zinc imprinting and replacing inorganic zinc with organic zinc on early performance of broiler chicks

The goal of this study was to determine the effects of feeding a zinc (Zn) deficient diet to broiler chicks for 96 h post-hatch followed by feeding diets with different Zn sources and supplemental levels (5 to 21 d) on the growth performance, tissue, and excreta Zn content. At the start of the study, four hundred 20-day-old male broiler chicks were divided into two groups. One group was fed a corn soybean meal based diet containing 25 mg of Zn/kg (imprinting diet, ID). The second group was fed the basal diet supplemented with 40 mg of Zn/kg from Zn oxide (ZnO) (non-imprinting diet, NID). Both groups were fed these diets for 96 h. At d 5, chicks from each group were randomly assigned to the dietary treatments consisting of the basal diet alone or the basal diet supplemented with 8 or 40 mg/kg Zn as ZnO or Zn proteinate. Main effects of post-hatch Zn ID were observed on feed intake and G:F. ID decreased (P < 0.05) feed intake and improved (P < 0.05) the gain to feed ratio (G:F) of 14 and 21 d old chicks compared to G:F of chicks fed NID. Additionally, G:F for 14 and 21 d was improved (P < 0.05) by interaction of Zn source × level. Furthermore, at d 21 chicks fed the ID had a lower (P < 0.05) Zn content in the tibia ash and excreta, and a higher (P < 0.05) Zn content in the pancreas tissue compared to chicks fed NID. These results suggest that Zn imprinting can affect body Zn stores and early performance.

Abstract P1-01-04: Nodal patterns of care in patients with invasive breast cancer treated with neoadjuvant systemic therapy: Results of a secondary analysis of TBCRC 017

Background: Neoadjuvant chemotherapy (NCT) to downstage locally advanced tumors and potentially allow breast conservation has increased. In parallel, the use of sentinel lymph node biopsy (SNB) and axillary node dissection has evolved. This analysis reports patterns of care for axillary evaluation at 8 NCI Comprehensive Cancer Centers in women receiving NCT.

Methods: Between 2002 and 2010, 770 women were retrospectively identified as having received NCT, 758 of who had nodal imaging either before or after NCT. Clinical, pathologic, and treatment data were collected. Univariate and multivariate analyses of covariates associated with axillary management were performed using logistic regression (SAS 9.2, Proc Logistic).

Results: Between 2002 and 2010, the odds of receiving a post-NCT SNB increased by 8% per year (p&lt;0.001). Rates of post-NCT SNB were significantly different in only one of eight institutions (p&lt;0.001), where pre-NCT nodal evaluation was made by SNB. The remainder of institutions used SNB following NCT. Of those who underwent post-NCT SNB, regardless of nodal status pre-NCT, 55% (171/314) had axillary lymph node dissection (ALND). Prior to NCT, 74% (564/758) of patients exhibited at least one abnormal lymph node on pretreatment imaging.

Imaging modalities used pretreatment to assess axillary lymph nodes Suspicious Nodes N (%)Ultrasound24 (4.3)Ultrasound+MRI218 (38.7)Ultrasound +MRI+CT103 (18.3)Ultrasound+MRI+CT+PET39 (6.9)Ultrasound+MRI+PET9 (1.6)Ultrasound+CT12 (2.1)Ultrasound+CT+PET8 (1.4)Ultrasound+PET3 (0.5)MRI36 (6.4)MRI+CT58 (10.3)MRI+CT+PET21 (3.7)MRI+PET9 (1.6)CT18 (3.2)CT+PET3 (0.5)CT+PET3 (0.5)TOTAL564 (100)

Of those, 52% (291/564) of the lymph nodes were sampled using fine needle aspiration (FNA) and 27% (149/564) were sampled with CNB. Odds of undergoing a core needle biopsy (CNB) at presentation for radiographically or clinically suspicious lymph nodes increased by 27% per year (p&lt;0.001). 57% (322/564) of all sampled lymph nodes were positive for malignant cells by either FNA or CNB. Of those with confirmed positive nodes at diagnosis, 26% (83/322) had nodal sampling with SNB after NCT. Of the 462 patients with pretreatment MRI suggesting an abnormal lymph node, 155 (33.5%) had a complete imaging response in the lymph nodes by MRI. Of those patients 32% (49/155) had SNB as their initial axillary evaluation after NCT, of which 45% (22/49) of those exhibited persistently positive nodes and underwent completion axillary node dissection.

Conclusions: Among a contemporary cohort of women receiving NCT, a significant trend was observed towards increased use of needle biopsy for patients with abnormal pretreatment nodal imaging at presentation and sentinel lymph node biopsy after NCT nodal evaluation. A trend was also observed over time towards greater use of post-NCT SNB in patients with confirmed pathologic positive nodes at presentation. These data demonstrate a trend towards less invasive assessment of suspicious lymph nodes both before and after NCT.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-01-04.

P2-08-02: Magnetic Resonance Imaging as a Predictor of Pathologic Response in Patients Treated with Neoadjuvant Systemic Treatment for Operable Breast Cancer (TBCRC 017)

Background: Increased pathologic complete response (pCR) rates observed with neoadjuvant chemotherapy for invasive breast cancer has prompted interest in whether patients with pCR can be identified preoperatively and potentially spared the morbidity of surgery. This multicenter retrospective study was performed to determine the accuracy of preoperative MRI in predicting pCR in the breast and whether MRI performance differs by molecular subtype, histology, and treatment regimen.

Methods: 770 women from 8 institutions were retrospectively identified as having received neoadjuvant systemic therapy with MRI obtained at baseline and after completion of systemic treatment. Tumor phenotypes were defined on the basis of estrogen and progesterone receptor (ER/PR or HR) and HER2 receptor status. Univariate and multivariate analyses of factors influencing radiographic complete response (rCR) and pCR were recorded, with rCR defined as resolution of any abnormal enhancement, mass, or distortion on MRI, and pCR defined as resolution of both invasive disease and DCIS.

Results: rCR and pCR for the total group were 182/746 (24%) and 179/746 (24%), respectively, with the highest rate of pCR seen among the triple-negative (TN; 57/155; 37%) and HR-/HER2+ (38/101; 38%) subtypes. Covariates significantly associated with rCR included T stage (p=0.0002), tumor grade (p=0.005), IHC phenotype (p=0.005), and chemotherapy regimen (p&lt;0.0001). On multivariate analysis, only tumor phenotype was independently associated with likelihood of rCR, with both TN (OR = 2.00, 95% CI 1.20−3.33) and HR-HER2+ (OR=2.30, 95% CI 1.09–4.83) more likely to achieve rCR than HR+HER- (reference group). Overall accuracy of MRI for prediction of pCR was 74%. Sensitivity, NPV, PPV, and accuracy differed significantly among tumor subtypes, with the greatest NPV in the HR-/HER2+ and TN subtypes (table1). Among patients with rCR, ER- status (OR=6.4, 95% CI 1.1 to 35.6), PR- status (OR=3.8, 95% CI 1.2 to 11.4), and tumor grade of 3 vs 1 or 2 (OR=2.49, 95% CI 1.22−5.07) were independently associated with likelihood of pCR. Discussion: MRI performance for predicting pCR in patients with invasive breast cancer receiving neoadjuvant systemic therapy differed significantly among breast cancer subtypes; however this difference is likely due to subtype differences in frequency of pCR and not to intrinsically better or worse MRI detection. The relatively low NPV of MRI following neoadjuvant systemic therapy does not support using MRI rCR alone to accurately identify those patients that can safely avoid surgery.

The Accuracy of MRI in Predicting Pathologic Complete Response in Invasive Breast Cancer Patients Receiving Neoadjuvant Systemic Treatment

Background: Magnetic resonance imaging (MRI) has increased sensitivity to detect abnormalities in breast tissue as compared with mammography or ultrasound. Published reports of MRIs ability to predict pathologic response to neoadjuvant chemotherapy have shown conflicting results that vary depending on baseline molecular characteristics and chemotherapeutic regimens, with some studies suggesting higher predictive accuracy in Her2 positive patients receiving trastuzumab. This study examines both the ability of MRI to predict pathologic response and how tumor molecular profiles and treatment regimens influence MRI sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Sensitivity, specificity, PPV, and NPV for the combination of post-treatment mammogram, ultrasound, and MRI studies in predicting pathologic complete response (pCR) was also explored.Methods: Eighty-one patients with invasive breast cancer treated with neoadjuvant systemic therapy between 2002 to 2009 and imaged pre and post-treatment with breast MRI were reviewed. Patient, tumor, and treatment characteristics including tumor grade, histologic type, receptor status (ER, PR, and Her2), breast cancer subtype [luminal A, luminal B, Her2 positive, triple negative (TN)], correlative pre- and post-treatment mammographic and ultrasound imaging, drug regimen, and pathologic findings were recorded. Complete pathologic response was defined as no residual invasive or pre-invasive disease in the breast.Results: Patients had the following subtypes of breast cancer: 21/81 (26%) luminal A, 13/81 (16%) luminal B, 23/81 (28%) Her2 positive, and 24/81(30%) TN. Of the Her2 positive, only 12/23 (52%) treated after May 2005 received adjuvant trastuzumab. Twenty patients (25%) had a complete radiographic response (rCR) on post-treatment MRI and 23/81(28%) had a pCR. The sensitivity, specificity, PPV, and NPV of MRI for predicting pathologic response was 57%, 88%, 65%, and 84%, respectively. Analysis of breast cancer subtype did not demonstrate a predilection in any particular subtype for correlation of radiographic and pathologic response, although MRI sensitivity (100%) and NPV (100%) were highest in luminal A disease, and specificity and PPV were highest for patients with ER negative (96% and 90%) and triple negative (100% and 100%) disease, respectively. Mammographic and ultrasound post-treatment findings of residual disease did not significantly correlate with pathologic findings in the setting of a rCR on MRI. Multivariate analysis of factors potentially influencing MRIs sensitivity and specificity failed to show that tumor characteristics (ER status, PR status, HER2 status) or neoadjuvant treatment (ACT vs other or trastuzumab) had any effect on these parameters.Conclusions: MRI has the highest specificity and PPV in the setting of ER negative and TN breast cancer. Although treatment results and breast cancer subtype did not influence the sensitivity, specificity, PPV, or NPV of MRI in predicting pathologic response, only half of the Her2 positive subset received trastuzumab. Results from an ongoing large multi-institutional study will further clarify these results.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4022.

The impact of optimal (<1cm) surgical debulking on survival at the time of recurrence in patients with uterine leiomyosarcoma (LMS)

16067

Objective: Uterine leiomyosarcoma (LMS) is an uncommon female malignancy with limited treatment options. To evaluate whether there exists a role for surgery at the time of recurrence, we performed an outcomes analysis from over 25 years of treating LMS at a single institution. Methods: Patients with uterine leiomyosarcoma who presented for treatment at the H. Lee Moffitt Cancer Center from 1981–2005 were identified from the cancer registry database. Patients who underwent surgery (with or without adjuvant treatment) at the time of first recurrence were compared to those patients who did not undergo surgery and were managed medically. Cox regression analysis (multivariate) was used to evaluate whether demographic or pathologic characteristics were associated with survival. Survival curves were estimated using the Kaplan-Meier method and p-values with 95% confidence intervals were generated using the log rank test. Results: Forty-six charts were reviewed to identify forty-one patients with leiomyosarcomas arising from the uterus and treated during 1981–2005. Of the forty-one patients identified, only 7% (N=3) are currently in remission, with a mean follow-up of 40 months from the time of first recurrence. Sixteen patients underwent surgery at the time of first recurrence, with 60% (N=10) of these patients having an optimal cytoreduction (<1cm). On multivariate analysis, post-menopausal status (p=0.011), the presence of tumor necrosis (p=0.038) and high pathologic grade (p=0.056) were significant variables associated with decreased survival. Median survival for optimally cytoreduced patients compared to patients medically managed patients was 55.5 months and 20 months, respectively. A trend towards improved survival in the optimally cytoreduced group was suggested but was not statistically significant (P=0.26) Conclusions: Uterine leiomyosarcoma is a disease with a poor prognosis and a high likelihood of recurrence. We have identified post-menopausal status, tumor necrosis, and pathologic grade as significant predictors of survival. Given the limited treatment options available and with a suggested trend toward improved survival, cytoreductive surgery at the time of recurrence may be worthy of future investigation.

No significant financial relationships to disclose.

A global genome damage score predictive of lung cancer patients outcome

Genome damage is a hallmark of human cancer. Efforts at assessing the impact of genome damage on tumor phenotype and patients outcome have focused on measurements of the relative DNA content in tumor cells compared to normal cells and the assessment of allelic loss at single or multiple selected loci that are thought to harbor genes important in cancer biology. We adapted a global, high-resolution genotyping method for determination of global and unbiased allelic loss. We generated a score, termed global genome damage score (GGDS), that is a continuous variable from zero to one and a measure of the extent of damaged DNA in individual tumors. In 71 patients with completely resected non-small-cell lung cancer, the GGDS ranged from 0.0006 to 0.5530 with a median value of 0.0401 indicating that between 0.06 and 55.3% of the genome has allelic loss. Patients with high scores (>0.04) had a significantly worse outcome than those with low scores (median overall survival time 35.5 vs >120.0 months, P=0.006 log-rank test; median disease-free survival 28.3 vs >120.0 months, P=0.003 log-rank test). This suggests that the clinical behavior of lung tumors with low GGDS is relatively benign whereas tumors with high GGDS are aggressive resulting in early death of patients.

Fatigue is a cause of functional dependence in older cancer survivors

8538

Background: The incidence and prevalence of cancer increase with age, but the impact of cancer and its treatment on the function of older cancer survivors is unknown. The aim of the study was to establish the prevalence of fatigue in older cancer patients off chemotherapy and the correlation of fatigue with Instrumental Activities of Daily Living (IADL) and Activities of Daily Living (ADL). Methods: We reviewed the cases of 214 individuals aged 70–90 with different cancers, subsequently processed through the Senior Adult Oncology Program (SAOP) over 4 months. All patients of the SAOP are evaluated for function, depression, comorbidity and fatigue, and all of them have a complete blood count. Depression is assessed with the geriatric depression scale (GDS); comorbidity with the cumulative illness rating scale for geriatrics (CIRS-G), and fatigue with the Fatigue symptom inventory (FSI). Results: We found that 82% of the patients reported some degree of fatigue and in 74% of cases fatigue interfered with their daily activities. The average fatigue severity was 5.38 ± 2.59; the FSI interference score 19.1 ± 16.1, the average number of days fatigued in a week 4.07 ± 2.6. Fatigue severity was positively correlated with CIRS_G score (p = 0.04), creatinine clearance (p = 0.02) performance status (PS) (p < 0.0001), GDS (p = 0.04); ADL (0.02); Minimental status (MMS) (p = 0.05); fatigue interference with Cr Clp = ).005); PD (p = 0.001) ADL (p = 0.02); GDS (p = 0.01), and fatigue frequency with CIRS-G (p = 0.04); Cr CL (p = 0.01), PS (p = 0.0001), ADL (p = 0.03); IADL (p = 0.03), and GDS(0.09). ADL dependence was related to intensity (0.02), interference (0.0001) and days of fatigue; IADL dependence to interference score (p = 0.0001) and days of fatigue (p = 0.017) and GDS to intensity (p = 0.004); interference score (p = 0. 006) and frequency of fatigue. Conclusions: Fatigue is common in long term older cancer survivors, and is associated with functional dependence and depression. Control of fatigue may improve the function of older cancer survivors

No significant financial relationships to disclose.

Prospective evaluation of RRM1 as a predictor of response to gemcitabine/carboplatin (GC) in non-small cell lung cancer (NSCLC)

7054

Background: RRM1 is the regulatory subunit of ribonucleotide reductase. It is a molecular target of G. RRM1 increases upon continuous exposure of cell lines to G. Preliminary data suggest improved survival for patients with low as opposed to high tumoral expression of RRM1 when treated with G-based chemotherapy. Methods: We determined the efficacy of G and C as induction therapy in patients with locally advanced NSCLC. Trial eligibility included measurable disease, no prior chemotherapy or RT, PS 0–1, and no weight loss. Patients were staged with CT, PET, and brain MRI. GC consisted of two 28-day cycles of G, 1,000 mg/m2 d1&8 and C, AUC 5 d 1. Unidimensional tumor measurements were obtained before and after GC. The study required tumor collection prior to therapy by core needle biopsy. Specimens were frozen in LN. Tumor cells were collected by LCM. Real-time quantitative RT-PCR gene analysis was performed in triplicate per sample for RRM1 and 18SrRNA. Results: Between 11/03 and 7/05, 30 eligible patients were enrolled, and the required tumor biopsies were obtained in all. In one patient, a pneumothorax developed that required chest tube placement. Disease response ranged from a 9% increase to a 100% decrease. 14/26 had SD, 11/26 PR, and 1/26 CR. The patients’ age was 47- 87 years; 12 were women; 13 had IIIA and 13 IIIB; 10 had sq, 7 ad, and 9 LC or NOS NSCLC. RRM1 expression ranged from 0.18 to 129.3. There was a significant (p = 0.014) inverse correlation (r = −0.474) between RRM1 expression and disease response. When grouping patients into those with response (CR/PR) and without response (SD), RRM1 expression was significantly (p = 0.027) associated with response. No significant association was found between RRM1 expression and other parameters. Conclusions: In a prospective clinical trial intratumoral RRM1 expression was significantly and inversely correlated with disease response to gemcitabine and carboplatin. These results strongly suggest that tumoral RRM1 expression is a major predictor of disease response to gemcitabine-based chemotherapy.

No significant financial relationships to disclose.

The benefits of a restaging PET scan after two cycles of neoadjuvant chemotherapy for resectable non-small cell lung cancer

17092

Background: Neoadjuvant chemotherapy can potentially improve the outlook of resectable non-small cell lung cancer (NSCLC). Whole-body 2-deoxy-2-[18F] fluoro-D-glucose (FDG)-PET is often used as an initial test to determine tumor resectability, but its role as a restaging test after neoadjuvant chemotherapy is unclear. Restaging PET after neoadjuvant chemoradiation helps identify unexpected distant metastasis and avoid unnecessary thoracotomy. We explored its benefits after neoadjuvant chemotherapy. Methods: Patients with stage IB-IIIA and selected IIIB resectable NSCLC received induction gemcitabine (1,000 mg/m2) and vinorelbine (25 mg/m2) on days 1, 8, 22, and 29. PET and CT scan were performed before enrollment and between day 43–50. Response from CT scan was defined by RECIST criteria; from PET, defined as >20% reduction in the SUVmax (a decrease of > 2 SD of spontaneous change in FDG uptake, previously validated). This abstract explores patients participated in a published prospective trial with available both pre- and post-treatment PET scans. Results: There were 19 patients: stage IB-7, stage IIB-2, and stage III-10. Median age was 67 years. Mean interval between staging and restaging PET scan was 59 days. By PET, 10 patients responded. By RECIST criteria, complete response occurred in 0, partial response in 6, and stable disease in 13 patients. Most successfully underwent a complete resection, but positive margins were present in 3; multi-station lymph node involvement was found intraoperatively in 1 patient. Overall median survival was 20.5 months. We found that restaging PET did not help identify any distant metastasis. Moreover, no survival difference was observed between PET responders and non-responders, though PET responders had more advanced stage than their counterparts: median survival 16 months vs. not reached (p = 0.08 adjusted for stage). PET response was correlated with RECIST response (p = 0.05) as well as the response as obtained by SUV max divided by the activity of contralateral lung or aorta ratio. Conclusion: Based on this small group of patients, a restaging PET scan obtained after two cycles of neoadjuvant chemotherapy among patients with resectable NSCLC did not appear to impact the decision on a planned thoracotomy.

No significant financial relationships to disclose.

A multi-institutional study of orthotopic neobladders: functional results in men and women

OBJECTIVES

To analyse the incidence of diurnal incontinence (DI) and nocturnal incontinence (NI), the need for intermittent catheterization (IC),and the rate of ureteric obstruction (UO) among a group of men and women with ileal and colonic orthotopic neobladders in four countries.

PATIENTS AND METHODS

In all, 138 patients (113 men and 25 women) had an orthotopic neobladder constructed after radical cystectomy for carcinoma. The mean(range) age was 61.3 (28-76) years and the follow-up 41 (6-144) months. All patients underwent surgery by experienced surgeons associated with the Confederation of American Urology. A retrospective evaluation was designed to review the functional results and the incidence of UO. The technique of orthotopic neobladder construction was at each surgeon's discretion. Various detubularized bowel segments were used, including ileum, colon or sigmoid. Patients were followed by chart reviews and personal interviews at 1, 3 and 6 months after surgery and then every 6 months, and were evaluated by a physical examination, urine analysis, cytology and renal ultrasonography.

RESULTS

An ileal or colonic neobladder was constructed in 74 and 64 patients, respectively. Five (7%), 23 (31%), 10 (14%) and 14(9.6%) with an ileal neobladder developed DI, NI, IC and UO, respectively; the respective values for patients with a colonic neobladder were eight (12%), 19 (30%), seven (11%)and 15 (12%). Statistical analysis by Fisher's exact test showed no significant differences between the ileal and colonic neobladder groups or with gender.

CONCLUSIONS

Using this specific protocol for evaluating many men and women with ileal and colonic orthotopic neobladders showed no significant differences in the incidence of DI, NI, IC or UO. Neobladders constructed from detubularized bowel, irrespective of bowel segment(s) used, can provide satisfactory diurnal results. A moderate incidence of NI and UO continue to be a problem.

Learning curves for breast cancer sentinel lymph node mapping based on surgical volume analysis

BACKGROUND

Implementation of new procedures, including lymphatic mapping for breast cancer, must be done and overseen by the medical community in a responsible way to ensure that the procedures are performed correctly. This study addresses the issues of adequacy of training and certification of surgeons performing lymphatic mapping. Ensuring quality in surgical care requires outcomes measures that are described in this study.

STUDY DESIGN

Sixteen surgeons performed lymphatic mapping in 2,255 patients with breast cancer using a combination blue dye and Tc99m-labeled sulfur colloid to identify the sentinel lymph nodes (SLNs). All participants were trained in a 2-day CME-accredited course. The Cox learning curve model (total number of mapping failures/total number of mapping cases) for a consecutive series of lymphatic mapping cases is described. The relationship of the Surgical Volume Index, the cases performed in a 30-day period, to the failure rate for each surgeon was modeled as a logistic regression curve (y = e(a+bx)/[1 + e(a+bx)]).

RESULTS

Surgeons performing less than three SLN biopsies per month had an average success rate of 86.23% +/- 8.30%. Surgeons performing three to six SLN biopsies per month had a success rate of 88.73% +/- 6.36%. Surgeons performing more than six SLN biopsies per month had a success rate of 97.81% +/- 0.44%.

CONCLUSIONS

This experience defines a learning curve for lymphatic mapping in breast cancer patients. Data suggest that increased volumes lead to decreased failure rates. These data provide surgeons performing SLN biopsy with a new paradigm for assessing their skill and adequacy of training and describes the relationship between volume of cases performed and success rate of SLN detection.

Expression of early lung cancer detection marker: hnRNP-A2/B1 and its relation to microsatellite alteration in non-small cell lung cancer

We have reported that a mouse monoclonal antibody, 703D4, which recognizes heterogeneous nuclear ribonucleoprotein A2/B1 (hnRNP-A2/B1) can frequently detect lung cancer in exfoliated sputum epithelial cells 1-2 years earlier than routine chest X-ray or sputum cytomorphology. We along with others have shown that microsatellite alteration (MA) at selected loci can be recognized in sputum cells prior to clinical lung cancer. The present study was undertaken to determine how frequently the expression of hnRNP-A2/B1 message is associated with neoplastic clonal expansion as shown by MA in 41 cases of non-small cell lung cancer (NSCLC). We used Northern blotting to evaluate hnRNP-A2/B1 mRNA expression in lung tumor and remote noninvolved lung. We evaluated microsatellite instability (i.e. shifts; MI) or loss of heterozygosity (LOH) with a panel of 13 microsatellite markers at loci identified previously as susceptible in NSCLC. Of the 41 tumors, 25 (61%) over-expressed hnRNP-A2/B1 and 33 (80%) demonstrated MA in at least one of 13 loci (58% in at least two loci). The association between MA (one locus) and the overexpression of hnRNP-A2/B1 is statistically significant (P=0.0082), and those lung tumors with MA at two or more loci were significantly more likely to over-express hnRNP-A2/B1 mRNA (P=0.004). MA of loci on 3p were the only MA statistically associated with hnRNP-A2/B1 message overexpression (P=0.001). We conclude that lung tumor cells undergoing clonal expansion frequently upregulate hnRNP-A2/B1.

Characteristics of the sentinel lymph node in breast cancer predict further involvement of higher-echelon nodes in the axilla: a study to evaluate the need for complete axillary lymph node dissection

BACKGROUND

Sentinel lymph node (SLN) biopsy techniques provide accurate nodal staging for breast cancer. In the past, complete lymph node dissection (CLND) (levels 1 and 2) was performed for breast cancer staging, although the therapeutic benefit of this more extensive procedure has remained controversial.

HYPOTHESIS

It has been demonstrated that if the axillary SLN has no evidence of micrometastases, the nonsentinel lymph nodes (NSLNs) are unlikely to have metastases.

OBJECTIVE

To determine which variables predict the probability of NSLN involvement in patients with primary breast carcinoma and SLN metastases.

METHODS

An analysis of 101 women with SLN metastases and subsequent CLND was performed. Variables included size of the primary tumor, tumor volume in the SLN, staining techniques used to initially identify the micrometastases (cytokeratin immunohistochemical vs hematoxylin-eosin), number of SLNs harvested, and number of NSLNs involved with the metastases. Tumor size was determined by the invasive component of the primary tumor. Patients with ductal carcinoma in situ who were upstaged with cytokeratin staining were considered to have stage T1a tumors.

RESULTS

Sentinel lymph node micrometastases (<2 mm) detected initially by cytokeratin staining were associated with a 7.6% (2/26) incidence of positive CLND compared with a 25% (5/20) incidence when micrometastases were detected initially by routine hematoxylin-eosin staining. Sentinel lymph node micrometastases, regardless of identification technique, inferred a risk of 15.2% (7/46) for NSLN involvement. As the volume of tumor in the SLN increased (ie, <2 mm, >2 mm, grossly visible tumor), so did the risk of NSLN metastases (P<.001).

CONCLUSIONS

Our study demonstrated that patients with micrometastases detected initially by cytokeratin staining had low-volume disease in the SLN with a small chance of having metastases in higher-echelon nodes in the regional basin other than the SLN. Characteristics of the SLN can provide information to determine the need for a complete axillary CLND. Complete lymph node dissection may not be necessary in patients with micrometastases detected initially by cytokeratin staining since the disease is confined to the SLN 92.4% of the time. However, the therapeutic value of CLND in breast cancer remains to be determined by further investigation.

Effect of fractionated regional external beam radiotherapy on peripheral blood cell count

PURPOSE

The purpose of this study was to assess the need for obtaining weekly complete blood count (CBC) values and to identify the pattern of changes in CBC during regional conventional fractionated radiotherapy.

METHODS AND MATERIALS

A retrospective analysis of CBC data on 299 adult cancer patients who received definitive conventional radiotherapy to head and neck (n = 95), chest (n = 96), and pelvis (n = 108) was performed. Temporal patterns and magnitude of change in white blood cells, neutrophils, lymphocytes, and platelets during radiotherapy were examined.

RESULTS

There were statistically significant declines in all counts, albeit not clinically significant. Notable differences between disease sites were found. The greatest weekly interval change in counts occurred during the first week of radiotherapy for all groups of patients. The mean WBC nadir values during treatment were 5.8 for head & neck, 6.8 for chest, and 5.4 for pelvis. The nadirs for all counts occurred toward the middle-to-end of radiotherapy. Lymphocytes were found to be more sensitive to radiotherapy than other leukocyte subcomponents.

CONCLUSION

Our study suggests that weekly CBC monitoring is not necessary for all patients undergoing standard fractionated radiotherapy. Baseline blood counts may be used to determine an optimal schedule for monitoring CBCs in patients receiving conventional radiation alone. Reduced monitoring of CBC may result in significant financial savings.

Importance of lymphatic mapping in ductal carcinoma in situ (DCIS): why map DCIS?

The appropriateness of sentinel lymph node biopsy in the management of patients with biopsy diagnoses of ductal carcinoma in situ (DCIS) or DCIS with microinvasion (DCISM) has not been established. Three hundred forty-one patients presented with a biopsy diagnosis of DCIS or DCISM. Two hundred forty (70%) underwent sentinel node biopsy at their definitive procedure. All clinical and pathologic data were collected prospectively. Of 224 patients with a biopsy diagnosis of DCIS 23 (10%) were upstaged to infiltrating ductal carcinoma (IDC) at their definitive therapy and of 16 patients with a biopsy diagnosis of DCISM seven (44%) were upstaged to IDC. Excisional biopsies were no more sensitive for detecting IDC than was core biopsy. Lymph node metastases were detected in 26 of 195 (13%) patients with a definitive diagnosis of DCIS, in three of 15 (20%) with a definitive diagnosis of DCISM, and in eight of 30 (27%) with a definitive diagnosis of IDC. Sentinel lymph node biopsy is a valuable tool in the treatment of patients with DCIS and DCISM and is particularly needed in those undergoing mastectomy. No "high-risk" group of patients can be identified for selective sentinel lymph node biopsy.

Learning curves and breast cancer lymphatic mapping: institutional volume index

INTRODUCTION

To date, studies of breast cancer lymphatic mapping (LM) have analyzed success with respect to individual surgeons. However, LM and sentinel lymph node biopsy (SLNBx) are procedures that require institutional multidisciplinary cooperation between the departments of radiology, pathology, and surgery. Thus, it is important to evaluate these procedures with respect to the institution. This study examines 30 institutions to clarify the value of the institutional volume index (IVI) (cases/month) to the outcome of LM and SLNBx in breast cancer.

METHODS

From July 1997 to July 1999, 30 institutions participated in the Department of Defense national breast LM trial. All participants underwent a 2-day training course for surgeons, nuclear medicine physicians, and pathologists. The records for each institution were prospectively accrued and submitted to a database. The false negatives, failure rates, and IVI were calculated for each institution. A logistic regression model plots the relationship between IVI and institutional failure rate. Using a multivariate analysis, mapping failure was analyzed as a function of case number with respect to the individual surgeon and the institution as a whole.

RESULTS

False negative results were demonstrated in only 5 (4%) cases among all institutions and were excluded from further analysis due to small numbers. Mapping failures were found in all but 7 of the 30 institutions whose data were complete. There were 71 mapping failures among 74 surgeons over 555 cases, which yielded an overall failure rate of 12.79% (71 555). The logistic regression model revealed an inverse relationship between IVI and institutional failure rate. However, the multivariate analysis revealed that the individual surgeon performance was the most significant factor in determining institutional mapping success.

CONCLUSION

Failure to map can be a function of multiple factors including surgical skill, surgical volume index, and injection method of the SLN patient, all under the quality control of an institution. The surgical failure rate on the other hand is a function of surgical skill, surgical volume, and injection methods. While differences in mapping success exist across institutions, this disparity is not due to factors associated with the institution as a whole, but lie with the individual surgeon.

Does prosthetic covering of nitinol stents alter healing characteristics or hemodynamics?

PURPOSE

To evaluate placement of polyester (Dacron) coverings on nitinol stents implanted in the canine aorta to determine the effect on cross-sectional lumen area, development of intimal hyperplasia, device endothelialization, and flow hemodynamics.

METHODS

Ten polyester-covered and 10 uncovered nitinol stents (60-mm length, 10- or 12-mm diameter) were deployed percutaneously in the normal infrarenal aorta of 20 adult mongrel dogs using random assignment. Angiography, intravascular ultrasound (IVUS), and duplex ultrasound performed at device deployment and before explantation at 6 weeks were used to measure aorta/device diameter and cross-sectional area. Pressure-perfusion-fixed aortic segments were compared for surface endothelialization (CD31 staining) and for thickness of neointimal formation.

RESULTS

All 20 endoluminal devices were accurately positioned in the infrarenal aorta without early or delayed evidence of device thrombosis, significant lumen narrowing, or device deformity. IVUS and duplex scanning identified no anatomical stenosis in either the covered or the bare devices by duplex ultrasound; peak systolic velocity measurements were similar (106+/-25 cm/s in the covered stent versus 96+/-25 cm/s for bare stents, p > 0.05). Mean neointimal thickness was significantly greater (p < 0.005) in the covered (326+/-145 microm) compared with the bare (219+/-62 microm) stents. Intima-to-media height ratios were greater in the covered stents (3.0+/-1.1 compared with 1.1+/-0.2, p < 0.003). Mean surface area endothelialization in the proximal, middle, and distal sections of each device was similar (p > 0.05) in covered (59%, 56%, and 69%) and bare (59%, 65%, and 53%) stents.

CONCLUSIONS

Deployment and balloon dilation of a covered nitinol stent in a nondiseased canine aorta increased neointimal development compared with an uncovered stent, but overall lumen cross-sectional area was preserved. No differences in device patency, intradevice thrombus formation, flow hemodynamics, or luminal endothelialization were demonstrated, despite a thicker intradevice neointima induced by the polyester covering.

The uncertainty principle and industry-sponsored research

BACKGROUND

Reporting of pharmaceutical-industry-sponsored randomised clinical trials often result in biased findings, either due to selective reporting of studies with non-equivalent arms or publication of low-quality papers, wherein unfavourable results are incompletely described. A randomised trial should be conducted only if there is substantial uncertainty about the relative value of one treatment versus another. Studies in which intervention and control are thought to be non-equivalent violates the uncertainty principle.

METHODS

We examined the quality of 136 published randomised trials that focused on one disease category (multiple myeloma) and adherence to the uncertainty principle. To evaluate whether the uncertainty principle was upheld, we compared the number of studies favouring experimental treatments over standard ones. We analysed data according to the source of funding.

FINDINGS

Trials funded solely or in part by 35 profit-making organisations had a trend toward higher quality scores (mean 2.94 [SD 1.3]; median 3) than randomised trials supported by 95 governmental or other non-profit organisations (2.4 [0.8]; 2; p=0.06). Overall, the uncertainty principle was upheld, with 44% of randomised trials favouring standard treatments and 56% innovative treatments (p=0.17); mean and median preference evaluation scores were 3.7 (1.0) and 4. However, when the analysis was done according to the source of funding, studies funded by non-profit organisations maintained equipoise favouring new therapies over standard ones (47% vs 53%; p=0.608) to a greater extent than randomised trials supported solely or in part by profit-making organisations (74% vs 26%; p=0.004).

INTERPRETATION

The reported bias in research sponsored by the pharmaceutical industry may be a consequence of violations of the uncertainty principle. Sponsors of clinical trials should be encouraged to report all results and to choose appropriate comparative controls.

Android obesity at diagnosis and breast carcinoma survival: Evaluation of the effects of anthropometric variables at diagnosis, including body composition and body fat distribution and weight gain during life span,and survival from breast carcinoma

BACKGROUND

Although a large body of research exists concerning pathologic prognostic indicators of the rate of incidence and survival from breast carcinoma, to the authors' knowledge very few studies have examined the effects of anthropometric variables such as height, obesity, weight gain in adulthood, timing of weight gain, and body composition to survival, although these variables are related to the incidence rate.

METHODS

The survival status of 166 patients diagnosed with primary breast carcinoma and followed for at least 10 years was obtained from the Cancer Center's registry, and significant anthropometric and other known prognostic indicators regarding survival after diagnosis were determined by Cox proportional hazards analysis.

RESULTS

Eighty-three of 166 breast carcinoma patients (50%) with up to 10 years of follow-up died of disease. Android body fat distribution, as indicated by a higher suprailiac:thigh ratio, was a statistically significant (P < 0.0001) prognostic indicator for survival after controlling for stage of disease, with a hazards ratio of 2.6 (95% confidence interval [95% CI], 1.63-4.17). Adult weight gain, as indicated specifically by weight at age 30 years, was a statistically significant (P < 0.05) prognostic indicator for survival with a hazards ratio of 1.15 (95% CI, 1.0-1.28). In addition, the authors observed the Quatelet Index, a negatively significant (P < 0.01) prognostic indicator for survival with a hazards ratio of 0.92 (95% CI, 0.87-0.98). Other markers of general obesity such as weight at diagnosis, percent body fat, and body surface area were not significant markers influencing survival. Similarly, height; triceps, biceps; subscapular, suprailiac, abdominal, and thigh skinfolds; waist and hip circumferences; family history; and reproductive and hormonal variables at the time of diagnosis showed no apparent significant relation to survival.

CONCLUSIONS

The results of the current study provide some evidence that android body fat distribution at diagnosis and increased weight at age 30 years increases a woman's risk of dying of breast carcinoma.

Evolution of techniques for ultrasound-guided palladium 103 brachytherapy in 950 patients with prostate cancer

PURPOSE

Brachytherapy is an effective, low-morbidity, cost-effective treatment for adenocarcinoma of the prostate. Although both iodine 125 and palladium 103 have been used extensively over the last 14 years, 103Pd (Theraseed) provides a more rapid initial dose and therefore better control of higher Gleason grade tumors. We assessed a highly refined methodology for 103Pd brachytherapy in patients with prostate cancer and compared outcomes before and after making adjustments in technique.

MATERIALS AND METHODS

Standard brachytherapy techniques were modified to include combination of preplanning with real-time adjustment, placing all needles at once to minimize prostate movement, using monitored anesthesia control sedation during preoperative volume study and cystoscopy, and several other small but important changes. Charts were reviewed from 950 patients treated with 103Pd implants from 1991 through 1999. Prostate-specific antigen (PSA) and biopsy data before and after 1993 were compared for 733 patients whose data qualified for analysis.

RESULTS

At 1 and 5 years after treatment, 85-88% of patients had stable PSA <1.5 ng/mL. Biopsies were negative in 90-94% at 2 years.

CONCLUSION

The modification in techniques provides positive results that remain stable over time.

Do cytokeratin-positive-only sentinel lymph nodes warrant complete axillary lymph node dissection in patients with invasive breast cancer?

The small number of nodes harvested with lymphatic mapping and sentinel lymph node (SLN) biopsy has allowed a more detailed pathologic examination of those nodes. Immunohistochemical stains for cytokeratin (CK-IHC) have been used in an attempt to minimize the false negative rate for SLN mapping. This study examines the value of CK-IHC positivity in predicting further lymph node involvement in the axillary basin. From April 1998 through May 1999, 519 lymphatic mappings and SLN biopsies were performed for invasive breast cancer. SLNs were examined by imprint cytology, hematoxylin and eosin (H&E), and CK-IHC. Patients with evidence of metastatic disease by any of the above techniques were eligible for complete axillary node dissection (CAND). The frequency with which these modalities predicted further lymph node involvement in the axillary basin was compared. Of the 519 lymphatic mappings, 39 patients (7.5%) had a CK-IHC-positive-only SLN. Five (12.8%) of these 39 patients had at least 2 SLNs positive by CK-IHC. Twenty-six of the CK-IHC-positive-only patients underwent CAND. Three of these 26 patients (11.5%) had additional metastases identified after CAND. The sensitivity levels with which each modality detected further axillary lymph node involvement were as follows: CK-IHC, 98 per cent; H&E, 94 per cent; and imprint cytology, 87 per cent. A logistic regression to compare the prognostic value of the three modalities was performed. All were significant, with odds ratios of 19.1 for CK-IHC (P = 0.015), 5.3 for H&E (P = 0.033), and 3.86 for imprint cytology (P = 0.0059). These data validate the enhanced detection of CK-IHC for the evaluation of SLNs. Detection of CK-IHC-positive SLNs appears to warrant CAND in patients with invasive breast cancer. However, the therapeutic value of CAND or adjuvant therapies based on CK-IHC-positive SLNs would be best answered by prospective randomized trials.

Minimally invasive treatment for localized adenocarcinoma of the prostate: review of 1048 patients treated with ultrasound-guided palladium-103 brachytherapy

PURPOSE

To assess the effectiveness of palladium-103 brachytherapy in stage T1 and T2 adenocarcinoma of the prostate.

PATIENTS AND METHODS

The charts of 1048 patients treated between 1991 and 1999 with transperineal realtime ultrasound-guided (103)Pd (Theraseed) implants were reviewed to assess the effects on serum prostate specific antigen (PSA) values and tissue (biopsy). Of the 1048 patients, 780 had sufficient data for this report. Preoperative total androgen blockade (leuprolide and flutamide) was used selectively in patients whose prostate size was >50 cc and those whose tumors had a Gleason score of >7.

RESULTS

At 1 year, 86% of the evaluable 766 patients had stable PSA concentration <1.5 ng/mL; at 5 years, 86% of the 166 patients with data available had stable PSA values <1.5 ng/mL. Biopsies were negative in 92% of the patients studied at 2 years. Patients with pretreatment PSA values <10 ng/mL had the best outcomes, and those treated with (103)Pd plus hormone ablation achieved PSA reduction more rapidly than those treated with radioisotope monotherapy. There was one disease-related death; the principal morbidity was short-term bladder and bowel irritation without permanent sequelae. Impotence occurred in approximately 15% of patients, and incontinence occurred in 5% of those who had undergone prior transurethral resection of the prostate.

CONCLUSION

The technique used in this study proved effective in reducing PSA concentrations to <1.5 ng/mL and in producing negative biopsies 1 and 2 years postoperatively. These results are comparable to those of external-beam radiation therapy and radical prostatectomy while demonstrating a significant reduction in morbidity.

Lymphatic mapping and sentinel lymph node biopsy in patients with melanoma of the lower extremity

Lymphatic mapping and sentinel lymph node biopsy is a new technique used in the surgical treatment of patients with malignant melanoma. The purpose of this study was to evaluate the results of this approach for patients with melanoma of the lower extremity. Between May of 1994 and June of 1997 at the H. Lee Moffitt Cancer Center and Research Institute, 85 consecutive patients with clinical stage I and II melanoma of the lower extremity underwent lymphatic mapping and sentinel lymph node biopsy. These nodes were identified in all 85 patients by intraoperative lymphatic mapping with both radiolymphoscintigraphy and a vital blue dye injection. Eleven patients (12.9 percent) had histologically positive sentinel lymph nodes, and 10 patients underwent inguinal complete lymph node dissections. All 10 patients had no further histologically positive lymph nodes confirmed by subsequent complete dissection. Among 74 patients with histologically negative sentinel lymph nodes, only 2 patients (2.7 percent) developed inguinal nodal metastases during a mean follow-up period of 21.8 months (range, 13.5 to 58.3 months). The sensitivity of lymphatic mapping and sentinel lymph node biopsy in this series was 100 percent and the specificity was 97.3 percent. Therefore, we conclude that the use of lymphatic mapping and sentinel lymph node biopsy can accurately stage patients with melanoma of the lower extremity and provide a rational surgical approach for these patients.

Surgical and endovascular intervention for infrainguinal vein graft stenosis

PURPOSE

The purpose of this study was to evaluate the stenosis-free patency of open repair (vein-patch angioplasty, interposition, jump grafting) and percutaneous transluminal balloon angioplasty (PTA) of 144 vein graft stenoses that were detected during duplex scan surveillance after infrainguinal vein bypass grafting.

METHODS

Patients who underwent revision of an infrainguinal vein bypass graft were analyzed for type of vein conduit, vascular laboratory findings leading to revision, repair techniques, assisted graft patency rate, procedure mortality rate, and restenosis of the repair site.

RESULTS

The time of postoperative revision ranged from 1 day to 133 months (mean, 13 months). One hundred eighteen primary and 26 recurrent stenoses (peak systolic velocity, >300 cm/s) in 52 tibial and 35 popliteal vein bypass grafts were identified by means of duplex scanning. The repairs consisted of 77 open procedures (vein-patch angioplasty, 28; vein interposition, 33; jump graft, 9; primary repair, 3) and 67 PTAs. No patient died as a result of intervention. Cumulative assisted graft patency rate (life-table analysis) was 91% at 1 year and 80% at 3 years. At 2 years, cumulative assisted graft patency rate was comparable for saphenous vein grafts (reversed, 94%; in situ, 88%; nonreversed, 63%) and alternative vein grafts (89%). Stenosis-free patency rate at 2 years was identical (P =.55) for surgical intervention (63%) and endovascular intervention (63%) but varied with type of surgical revision (P =.04) and time of intervention (<4 months, 45%; >4 months, 71%; P =.006). The use of duplex scan-monitored PTA to treat focal stenoses (<2 cm) and late-appearing stenoses (>3 months) was associated with a stenosis-free patency rate that was 89% at 1 year. After intervention, the alternative vein bypass grafts necessitated twice the reinterventions per month of graft survival (P =.01). Bypass graft to the popliteal versus infrageniculate arteries, site of graft stenosis (vein conduit, anastomotic region), and repair of a primary versus a recurrent stenosis did not influence the outcome after intervention.

CONCLUSION

The revision of duplex scan-detected vein graft stenosis with surgical or endovascular techniques was associated with an excellent patency rate, including when intervention on alternative vein conduits or treatment of restenosis was necessary. When PTA was selected on the basis of clinical and duplex scan selection criteria, the endovascular treatment of focal vein graft stenosis was effective, durable, and comparable with the surgical revision of more extensive lesions.

Ischemia detection in women: the diagnostic value of exercise QRS duration changes

AIM

To compare the diagnostic accuracy of exercise electrocardiographic (ECG) ST-T changes and QRS duration changes as a means of ischemia detection in a female population.

METHODS AND RESULTS

A total of 101 women from a pool of 318 referred for ECG stress testing underwent standard testing using ST-T criteria with the additional measurement of QRS duration before and at peak exercise using a new computerized optic scanner for precise QRS duration measurement. The diagnostic accuracy of the test was determined using planar thallium stress testing as a "gold standard." For the overall population, the sensitivity of ST-T criteria was 47% with a specificity of 58%. The sensitivity of QRS duration changes was 91% with a specificity of 89%. For Group 1 (age 27-50) the sensitivity of the ST-T criteria was 40% with a specificity of 58%. The sensitivity of the QRS duration changes was 80% with a specificity of 83%. For Group 2 (age 51-83), the sensitivity of the ST-T criteria was 43% with a specificity of 56%. The sensitivity of the QRS duration changes was 94% with a specificity of 90%.

CONCLUSION

In our female population exercise, QRS duration changes using our computerized method were better markers of ischemia than standard ST-T criteria.

Development of a head and neck companion module for the quality of life-radiation therapy instrument (QOL-RTI)

PURPOSE/OBJECTIVE

A review of available head and neck quality of life (QOL) instruments reveals them to inadequately address important radiation related side effects, or to be too cumbersome for routine use. The purpose of this study was to develop a head and neck disease specific module as a companion to the previously developed quality of life - radiation therapy instrument (QOL-RTI). The goal was to create a more complete, yet concise, head and neck site-specific module geared toward patients receiving radiation therapy for head and neck cancer.

METHODS AND MATERIALS

This exploratory study included 34 consecutive patients undergoing definitive radiotherapy over a 6-7 week course (60-79.8 Gy). We developed and administered a 14-item questionnaire to all eligible patients treated with radiotherapy for head and neck cancer who were not already registered in another research study assessing quality of life (e.g., RTOG). During the treatment period, the QOL-RTI general tool and the head and neck (H&N) module were administered as follows: at baseline, at week four (for test-retest), and at the end of the treatment period. For validation purposes the QOL-RTI/H&N was compared to the functional assessment cancer tool head and neck (FACT-H&N) questionnaire. The FACT-H&N was administered one time at week 4, on the same day as the QOL-RTI/H&N. This report includes the treatment phase of the study (during the course of radiation).

RESULTS

Mean age was 62 years (range 40-75). Internal consistency of the module was satisfactory (Chronbach's alpha = 0.85). Test-retest yielded a correlation coefficient of 0.90 (p < 0.001). Concurrent validity, established by comparing the module to the FACT/H&N , yielded a correlation coefficient of 0.85. Significant changes in quality of life scores during a course of radiation was noted for both general quality of life tool and the site specific module. For the head and neck module, the difference in the mean baseline (7.17) and end of treatment scores (4.20) was 2.94, or 42% change (p < 0.0001). A smaller, yet still significant, difference in scores was seen in the general QOL tool (22 % change, p = 0.001). Item analysis of the module revealed statistically significant (p < 0.05) worsening in quality of life scores in the following areas: pain in throat, swallowing difficulty (meat/bread and liquids), changes in mucous and saliva, changes in taste, difficulty chewing, trouble with coughing, and speech difficulties. Items that were not significant were pain in the mouth, and appearance.

CONCLUSION

These initial results suggest that the H&N companion module to the QOL-RTI is a valid and reliable tool that is responsive to changes in QOL during a course of H&N radiation therapy. This tool differs from existing H&N tools by including specific assessments of mucous, saliva, taste, cough, and local pain in a concise format. Significant changes in QOL scores were noted in all of these items. Evaluation of the tool in the post-treatment period (follow-up) is ongoing.

Efficacy of hyperthermic isolated limb perfusion for extremity-confined recurrent melanoma

BACKGROUND

Recurrent melanoma of the extremity has been treated by local excision, systemic chemotherapy, amputation, or a combination of these approaches. Hyperthermic isolated limb perfusion (HILP) provides a method of limb preservation through isolation, allowing the administration of chemotherapy in higher doses than is possible through systemic treatment.

METHODS

An experimental group of 59 HILP patients with melanoma recurrences of the extremity was studied prospectively. A control group of 248 melanoma patients with similar recurrences was excluded from HILP because their recurrences were in non-extremity locations. The experimental group underwent HILP and excision; the control group had excision only. The experimental procedure consisted of vascular isolation of the affected extremity and a 1-hour perfusion with melphalan. Temperatures were maintained at 40 degrees C in the perfusion circuit.

RESULTS

The HILP patients had a lower rate of locoregional recurrence (P=.028) and demonstrated increased survival (P=.026) compared to the control group. In multivariate regression analysis, which included age, ulceration and thickness of the primary, and the treatment variable of perfusion, age (P=.02) and perfusion for the treatment of recurrence (P=.006) were significant predictors of survival.

CONCLUSIONS

HILP improves prognosis by sterilizing the treated extremity, controlling locoregional disease, and perhaps preventing metastasis, thus having a positive impact on overall survival.