Timing of surgery related to menstrual cycle and prognosis of premenopausal women with breast cancer

The influence of the timing of surgery in relation to the menstrual cycle on the survival of breast cancer patients has been both advocated and disputed. The records of 165 premenopausal M- breast cancer women consecutively operated from 1977 to 1991 were reviewed. All patients underwent modified radical mastectomies or quadrantectomies plus postoperative radiotherapy. Node-positive patients received adjuvant chemotherapy. Cox regression analysis was used to estimate the relative risk (RR) of death in three models including timing of surgery, age, histology, pT and pN. In each model, patients were divided into two groups according to the criteria proposed by Badwe, Hrushesky, and Senie. Multivariate analysis showed a significant association between pT and pN and survival, whereas no association with survival was observed for the timing of surgery according to either Badwe or Hrushesky or Senie (RR = 1.26, RR = 0.91 and RR = 0.88 respectively). Consensus on the menstrual phase related to the expected best prognosis is still required.

Conventional isolated hyperthermic antiblastic perfusion in the treatment of recurrent limb melanoma

Hyperthermic Antiblastic Perfusion (HAP) is a widely used method for the treatment of recurrent limb melanoma. In terms of tumor response, locoregional control and survival HAP has led to better results than those achieved with any other treatment. The aim of this report is to analyze our own experience with HAP in locally advanced limb melanoma. Thirty-two patients were submitted to HAP. HAP lasted 60 minutes, with maximal local temperature of 40.5-42 degrees C using melphalan 10 mg/L limb volume as antiblastic agent. Twenty patients had in-transit metastases and 12 local recurrence. Regional nodes were involved in 12 patients. Systemic leakage monitored with 125I or 99Tc ranged between 5-30% (mean 14%). No operative mortality nor major complications occurred. Local toxicity scored Wieberdink grade I in 8 patients, grade II in 17, grade III in 6 and grade IV in 1 case. Response rate (UICC) in the 16 patients treated with unexcised lesions was 94% (56% complete responses). With a median follow-up of 29 months (2-126) 14 patients relapsed after a median time of 10 months, and 17 patients are currently disease free, 3 of these are being reexcised and 3 re-perfused. Actuarial 5 years survival was 64%, with 39% disease free to the first relapse. Our results are consistent with the literature indicating HAP as a safe procedure with a high evidence of clinical responses.

Pharmacological control of intimal hyperplasia in small diameter polytetrafluoroethylene grafts. An experimental study

OBJECTIVE

The efficacy of a postoperative treatment with Low molecular weight heparin (LMWH) vs Ticlopidine in controlling early thrombosis, intimal hyperplasia and growth of true endothelial cells in small prosthetic expanded polytetrafluoroethylene (ePTFE) grafts (4 mm) interposed in the carotid artery of sheep has been evaluated.

EXPERIMENTAL DESIGN

Thirty animals were randomized into three different groups: control group (CTRL); ticlopidine hydrochloride (TICL) 250 mg/b.d. by month for 4 weeks from day 1; LMWH 3,085 IU AXa s.c. preoperatively and once a day for the same period.

RESULTS

Complete thrombosis of the graft occurred in 7 sheep in the CTRL group and 5 in the TICL group while 2 partial thrombosis were observed in the LMWH group (n.s.). In all the evaluable cases, hyperplasia was observed in both anastomotic areas and did not involve the middle portion of the graft. The mean +/- SD intimal thickness was 603 +/- 20 micron in the CTRL group, 356 +/- 10 in the TICL group and 152 +/- 17 in the LMWH group (p < 0.001) compared to the 60 +/- 12 of the normal intima. True endothlial cells were found mainly in the LMWH group close to the arterial anastomosis.

CONCLUSIONS

The postoperative use of LMWH seems to inhibit intimal hyperplasia, with interesting results also on patency and cellular coverage. Further studies are necessary to support this promising trend.

Palliative chemoembolization of hepatocellular carcinoma with mitoxantrone, Lipiodol, and Gelfoam. A phase II study

Transcatheter chemoembolization, in conjunction with various drugs, has been widely used for palliative treatment of hepatocellular carcinoma. A phase II study was carried out on mitoxantrone chemoembolization. High risk cirrhotic patients were excluded from this study. Fourteen mg/m2 mitoxantrone and up to 20 ml Lipiodol were injected, followed by Gelfoam embolization as indicated. Thirty-seven patients (33 with cirrhosis) were treated. Sixty-nine cycles were delivered, with mean (+/-SD) Lipiodol and emulsified mitoxantrone doses of 11.3+/-3.8 ml and 11.8+/-5.2 mg, respectively. Thirteen, 16, and 8 patients received one, two, and three cycles, respectively, with time intervals of 123+/-60 days. Thirty patients received Gelfoam embolization at the first cycle, 9 at the second and 4 at the third. No treatment-related deaths occurred. Complications were mild and transient, including nausea/vomiting in most cases, fever over 38 degrees C 67%, pain 74%, ascites 8%, jaundice 3%, bleeding 3%, pancreatitis 3%, myelosuppression 44%, diarrhea 5%. Treatment response rate was 49% (including 16% minor responses) with 16% early progressions. With a median follow-up of 12 months, the 12-month response duration and survival rates were 56% and 79% respectively. Transcatheter chemoembolization with mitoxantrone appears to be a promising method for the palliation of advanced hepatocellular carcinoma, and deserves to be evaluated in well controlled randomized studies.

Screening for abdominal aortic aneurysms and associated risk factors in a general population

OBJECTIVES

To evaluate the prevalence of abdominal aortic aneurysms (AAA) in a general population and to compare the results with those of similar studies in other countries.

DESIGN

Ultrasound screening study and collection of clinical and biochemical data.

SETTING

An urban Health Service District in Genoa, Italy.

MATERIALS

A general population, aged 65-75 years, invited by personal letter between 1991-1994.

RESULTS

1601 subjects (741 males and 860 females) out of 2734 invited (58.5%) were evaluated. According to the ultrasound findings, 27 patients (1.7%) had an aortic dilatation of 26-29 mm; an AAA of 30-39 mm was found in 37 (2.3%) and an AAA > or = 40 mm in 33 (2.1%). The overall prevalence for AAA was 4.4% (8.8% in males and 0.6% in females respectively). The prevalence of smoking, alcohol consumption, coronary heart disease, chronic obstructive pulmonary disease and arterial disease were significantly higher in patients with AAA (p < 0.01).

CONCLUSIONS

Ultrasound screening for AAA is a reliable and useful method and should be focused on men, regardless of concurrent disease.

[Screening for abdominal aortic aneurysms in the general population. Preliminary results]

Between March 1991 and April 1993, 1188 subjects aged 65-75 years, out of 2734 invited, underwent abdominal ultrasound for screening of asymptomatic abdominal aortic aneurysms (AAA). For each patient the maximal anteroposterior and transverse diameters of the suprarenal and infrarenal aorta were measured. According to the literature data an AAA is defined as an aortic dilatation > 29 mm. AAA < 40 mm are followed by ultrasound every 6 months and the AAA > 39 mm are considered for surgical repair after complete clinical work-up. In addition any aortic dilatation ranging 26-29 mm is followed too, using the same criteria. The aorta was normal in 1112 patients (95.12%), an infrarenal aortic dilatation was found in 21 patients (1.79%), an AAA < 40 mm in 15 patients (1.28%) and an AAA > 39 mm in 21 patients (1.79%). The global prevalence of AAA > 29 mm was 3.07% (0.3% for the females and 6.8% for the males), similar to that reported by other authors. The statistically significant (p < 0.01) risk factors were: smoking, alcohol consumption, coronary disease and chronic lung obstruction. Hypertension and dyslipidaemia were not significant (but HDL-cholesterol and Apo-B), according to a different etiology of the aneurysms. In addition 38.5% of the patients had total cholesterol > 240 mg/dl but only 34.9% of these was under medical treatment and/or on a diet. Our preliminary data confirm the results of similar studies in other countries: screening for AAA is worthwhile on the general population and, looking to a better cost-benefit rate, it might be focused only on males.

End-to-end arteriovenous fistula for chronic haemodialysis: 11 years' experience

Between January 1979 and December 1989, an end-to-end arteriovenous fistula for chronic haemodialysis was performed at the anatomical snuffbox in 140 patients with a mean age of 51 (range 14-81) years and at the wrist in 248 with a mean age of 53 (range 19-83) years. The choice of site depended on the characteristics of the vessels and on the arterial blood pressure. No operative mortality, major complications or side effects occurred. The primary median patency for the arteriovenous fistula at the anatomical snuffbox was 36 months with a patency rate of 77.3% at 1 year, 36.3% at 5 years and 18.9% at 10 years. For the arteriovenous fistula at the wrist the median patency was 64 months and the patency rate 75.5% at 1 year, 54.5% at 5 years and 30.7% at 10 years. The higher incidence of thromboses in the patients with a fistula in the snuffbox may reflect an excessive enthusiasm for this technique because of initially promising results.

[Continuous sinusoid systemic Fudr infusion in advanced colorectal carcinoma. Preliminary experience]

Sinusoidal circadian continuous infusion with a maximal flow rate in the afternoon (3-9 pm) reduces Fudr toxicity. In order to estimate if the reported lower toxicity is merely due to the quasi-intermittence of the daily dose or to the circadian rhythm of infusion. Ten patients with widespread cancer (9 colorectal and 1 renal) underwent sinusoidal continuous iv Fudr infusion with the peak level in antiphase (ie 68% of the dose from 3 to 9 am) as compared with the Römeling shape. An initial dose of 0.15 mg/kg/d for 14 days monthly has been given, escalating it every cycle by 0.025 mg/kg/d increments until toxicity. Mean (+/- SD) number of cycles has been 4.1 +/- 2.1 (range 2-8), maximal dose given has been 0.2 mg/kg/die in 5 patient and mean dose intensity of 0.570 +/- 0.04. Gastrointestinal toxicity consisted of nausea/vomiting WHO grade 1 in one patient and diarrhoea grade 1 in two, grade 2 and 3 in one and one case. Toxicity and dose intensity of both sinusoidal infusion seem to be similar and allow higher dose of Fudr than continuous constant infusion. Some other studies have to be done to include pharmacokinetics evaluation in order to estimate chronobiologic implication in continuous Fudr infusion.

[Clinical use of a totally implantable and programmable pump for the infusion of drugs]

Totally implantable programmable systems allow preordained complex continuous infusion of drugs. Sixteen totally programmable implantable pumps (Medtronic DAD) have been implanted in fifteen advanced colorectal and renal cancer patients for continuous ia and iv sinusoidal Fudr infusion. Median duration of pump function was 125 days (range 46-468), there was observed only one case of malfunction device which required the implant of a new device, and three complications of pump pocket (seroma, hematoma and infection) without interrumption of chemotherapy for clinical causes. The use of totally implantable programmable systems provides and important clinical improvement in controlled long-term drugs administration improving quality of life and duration of chemotherapy.

[Modification of the in situ saphenous vein technique as vascular access for chronic hemodialysis treatment. Technical note]

A modification of the "in situ" saphenous vein graft above the knee is used to perform vascular access for maintenance haemodialysis when the upper arms are no more suitable. This technique is easy to perform with only one vascular anastomosis and the above knee saphenous vein is entirely available for venipuncture. The possible use of the Fogarty catheter form both sides and the convenient cost-benefit rate make this method indeed interesting.

[Hyperthermic-antiblastic isolation perfusion for advanced melanoma of the limbs. The technic, immediate results and a review of the literature]

Hyperthermic antiblastic isolated perfusion is a method largely used for the treatment of locally advanced limb melanoma. The method requires vascular isolation and hyperthermic perfusion of the limb using an extracorporeal circuit and administering the melphalan as antiblastic drug. Twenty-six patients with primary or recurrent melanoma of the limbs have undergone this treatment at our Institute. There were no cases of operative mortality and systemic toxicity was negligible. The local complications were transitory and no patient showed symptoms of nervous toxicity or permanent functional damage. Two cases of deep thrombophlebitis and two of lymphocele were documented a few months after treatment. Four clinically complete responses, 3 partial and 2 cases of stable disease were observed in the 9 patients treated with unexcised lesions. Our data like the totality of the present experience points to the safety of this method in the therapy of locally advanced limb melanoma. Nevertheless further controlled studies are required to define its role in order to improve survival.

Serum, urine and peritoneal fluid levels of 5-FU following intraperitoneal administration

Seven patients with advanced colon cancer, refractory to conventional chemotherapy, and malignant disease confined to the intra-abdominal space received a total of 24 consecutive courses of ip 5-Fluorouracil (5-FU). 5-FU 1000 mg was administered in 2 L of warm (37 degrees C) dialysate daily for five consecutive days every 28 days. 5-FU concentrations in serum, peritoneal fluid and urine were measured by high pressure liquid chromatography (HPLC). The mean disappearance half-life of 5-FU from the peritoneal fluid was 1.6 hours with a mean permeability area product (PA) of 22.4 ml/min. The mean peritoneal AUC was 450 +/- 165 times greater than the mean serum AUC. Ip 5-FU treatment is well tolerated, can be safely administered on an outpatient basis and produces a significant pharmacological advantage over conventional routes of administration.