The lung immuno-oncology prognostic score (LIPS-3): a prognostic classification of patients receiving first-line pembrolizumab for PD-L1 ≥ 50% advanced non-small-cell lung cancer

Background

To stratify the prognosis of patients with programmed cell death-ligand 1 (PD-L1) ≥ 50% advanced non-small-cell lung cancer (aNSCLC) treated with first-line immunotherapy.

Methods

Baseline clinical prognostic factors, the neutrophil-to-lymphocyte ratio (NLR), PD-L1 tumour cell expression level, lactate dehydrogenase (LDH) and their combination were investigated by a retrospective analysis of 784 patients divided between statistically powered training (n = 201) and validation (n = 583) cohorts. Cut-offs were explored by receiver operating characteristic (ROC) curves and a risk model built with validated independent factors by multivariate analysis.

Results

NLR < 4 was a significant prognostic factor in both cohorts (P < 0.001). It represented 53% of patients in the validation cohort, with 1-year overall survival (OS) of 76.6% versus 44.8% with NLR > 4, in the validation series. The addition of PD-L1 ≥ 80% (21% of patients) or LDH < 252 U/l (25%) to NLR < 4 did not result in better 1-year OS (of 72.6% and 74.1%, respectively, in the validation cohort). Eastern Cooperative Oncology Group (ECOG) performance status (PS) of 2 [P < 0.001, hazard ratio (HR) 2.04], pretreatment steroids (P < 0.001, HR 1.67) and NLR < 4 (P < 0.001, HR 2.29) resulted in independent prognostic factors. A risk model with these three factors, namely, the lung immuno-oncology prognostic score (LIPS)-3, accurately stratified three OS risk-validated categories of patients: favourable (0 risk factors, 40%, 1-year OS of 78.2% in the whole series), intermediate (1 or 2 risk factors, 54%, 1-year OS 53.8%) and poor (>2 risk factors, 5%, 1-year OS 10.7%) prognosis.

Conclusions

We advocate the use of LIPS-3 as an easy-to-assess and inexpensive adjuvant prognostic tool for patients with PD-L1 ≥ 50% aNSCLC.

•

Immunotherapy/chemoimmunotherapy combinations are currently not superior to immunotherapy alone for high PD-L1 aNSCLC.

•

NLR with a cut-off of 4 was validated as an independent prognostic factor for immunotherapy in high PD-L1 aNSCLC.

•

The addition of either PD-L1 ≥ 80% or LDH < 252 U/l to NLR < 4 did not result in better prognostic stratification.

•

The LIPS-3 is a validated 3-class prognostic classification based on the NLR, ECOG PS and pretreatment steroids.

•

The LIPS-3 is a routinely assessable adjuvant prognostic tool for high PD-L1 aNSCLC patients.

AMS assessment of U-contamination of structural materials of the Garigliano NPP under decommissioning

The assessment of the radiological impact of decommissioning activities at a Nuclear Power Plant requires a detailed mapping of the distribution of radionuclides both in the environment surrounding the NPP and in its structural material. The detection of long-lived actinide isotopes and possibly the identification of their origin is particularly interesting and valuable if ultrasensitive measurement of the relative abundance of U isotopes is performed via Accelerator Mass Spectrometry (AMS). In this paper we present an investigation carried out on the structural materials of the Garigliano NPP aiming to determine the abundance of ^235,236,238U in the various compartments of the plant buildings under decommissioning. Since the expected values both for isotopic ratios and total U concentrations range over different orders of magnitude, we have developed a novel methodology for the measurement of ^234,235U/²³⁸U isotopic ratios in low U concentration samples. This allowed a systematic investigation of the distribution of all U isotopes in concrete and metal matrices of the NPP. The behavior of ^235,236U/²³⁸U isotopic ratios in the different compartments of the NPP is discussed. The correlation of these ratios with ⁶⁰Co and ¹³⁷Cs specific activities is also studied to show a different behavior for concrete and metal samples. These data represent a very valuable information to direct the decommissioning procedures under course.

Short-Term Weekly Neoadjuvant Chemotherapy in the Treatment of Locally Advanced Cervical Cancer

Twenty patients with locally advanced cervical cancer (FIGO stage Ib-IIa “bulky”/VIIb) were treated with three courses of weekly PVB (day 1: cisplatin, 50 mg/m2; vincristin, 1 mg/m2; bleomycin, 30 IU over 24-hr) in a neoadjuvant setting. Toxicity was generally mild (no grade 3-4 toxicity was observed), and the treatment was well tolerated without reduction of programmed dose intensity. Fourteen patients (70%) experienced a clinical response and underwent surgery within 20 days after the third course of chemotherapy. Six patients (30%) with stable disease were treated with salvage radiotherapy. Two of the 14 responders experienced a pathologic complete response (14.2%); microscopic disease was detected in one patient with clinical complete response. Pelvic node metastases were found in 4/14 patients (28.5%) and microscopic parametrium involvement in 3/14 (21.4%). All 14 patients had free margins of resection. A short-term weekly platinum-based chemotherapy is highly effective, has little toxicity, and allows a prompt salvage therapy for nonresponding patients.

Multifaceted Quadruplet of Low-Lying Spin-Zero States in ^{66}Ni: Emergence of Shape Isomerism in Light Nuclei

A search for shape isomers in the ^{66}Ni nucleus was performed, following old suggestions of various mean-field models and recent ones, based on state-of-the-art Monte Carlo shell model (MCSM), all considering ^{66}Ni as the lightest nuclear system with shape isomerism. By employing the two-neutron transfer reaction induced by an ^{18}O beam on a ^{64}Ni target, at the sub-Coulomb barrier energy of 39 MeV, all three lowest-excited 0^{+} states in ^{66}Ni were populated and their γ decay was observed by γ-coincidence technique. The 0^{+} states lifetimes were assessed with the plunger method, yielding for the 0_{2}^{+}, 0_{3}^{+}, and 0_{4}^{+} decay to the 2_{1}^{+} state the B(E2) values of 4.3, 0.1, and 0.2 Weisskopf units (W.u.), respectively. MCSM calculations correctly predict the existence of all three excited 0^{+} states, pointing to the oblate, spherical, and prolate nature of the consecutive excitations. In addition, they account for the hindrance of the E2 decay from the prolate 0_{4}^{+} to the spherical 2_{1}^{+} state, although overestimating its value. This result makes ^{66}Ni a unique nuclear system, apart from ^{236,238}U, in which a retarded γ transition from a 0^{+} deformed state to a spherical configuration is observed, resembling a shape-isomerlike behavior.

Triplet schedule of weekly 5-fluorouracil and alternating irinotecan or oxaliplatin in advanced colorectal cancer: a dose-finding and phase II study

A weekly administration of alternating irinotecan or oxaliplatin associated to 5-Fluorouracil in advanced colorectal cancer was planned in order to evaluate a new schedule maintaining dose intensities of each drug as in double combinations and tolerability of the triplet association. The following weekly schedule was administered: irinotecan, days 1 and 15; oxaliplatin, days 8 and 22; 5-fluorouracil (5-FU) over 12-h (from 10:00 p.m. to 10:00 a.m.) timed flat infusion, days 1-2, 8-9, 15-16 and 22-23, every 4 weeks. Dose- finding and phase II study were planned. Thirteen patients were enrolled in the dose-finding study and 23 in the phase II study. The recommended doses of our study are: irinotecan 160 mg/m(2); oxaliplatin 80 mg/m(2); 5-FU 900 mg/m(2). The dose-limiting toxicity was diarrhea (35% of patients) but no cases of febrile neutropenia were observed. In 30 patients assessable for response two complete (6.7%) and 18 partial (60%) responses were observed, for an overall response rate of 66.7% (alpha 0.05, CI+/-17). The triplet association using this weekly alternating schedule is an active and well-tolerated outpatient regimen. Surgical removal of residual disease was considered in 5 patients and a radical resection was performed in 5 patients (147 %).

“Poker” schedule of weekly alternating 5-fluorouracil, irinotecan, bevacizumab, and oxaliplatin (FIR-B/FOX) in advanced colorectal cancer: A phase II study

4125

Background: Triplet combinations associating antimetabolites with irinotecan (CPT-11) and/or oxaliplatin (OHP) and/or bevacizumab (BEV) show increased activity in same phase III studies vs doublets, with objective responses (OR) between 40% and 60%. Thus we evaluated in a phase II study the addition of BEV to the triplet combination CPT-11/OHP/5-fluorouracil (5-FU) as first line chemotherapy in metastatic colorectal carcinoma (MCC). Methods: Main inclusion criteria: histologically diagnosis of colorectal cancer (CRC) with measurable disease; age 18–75 yrs; adequate bone marrow reserve and renal and hepatic function; no cardiac diseases; no uncontrolled hypertension; no thromboembolic diseases or coagulopathy, no preexisting bleeding diatheses. Treatment schedule: weekly 5-FU 12-h timed-flat-infusion (from 10:00 pm to 10:00 am) 900 mg/m2/d 1–2, 8–9, 15–16 and 22- 23; CPT-11 160 mg/m2 plus BEV 5 mg/kg days 1 and 15; OHP 80 mg/m2 days 8 and 22, every 4 weeks. A Simon two-stage optimal design was planned: power 80%, error probability α 5%, error probability β 20%, P0 50%, P1 70%, sample size 43 pts (I stage 8/15 OR; II stage 26/43 OR). Primary endpoint: OR. Secondary endpoints: time to progression (TTP), overall survival (OS), toxicity and quality of life. Results: Forty-eight pts were enrolled. Median number of cycles per patient was 5 (range 1–9). In the expected 43 pts assessable intent-to-treat (ITT), OR were 84% (α0.05, CI +12): 2 complete and 34 partial responses. In the overall 48 pts, 46 were assessable ITT: OR 80% (α0.05, CI +12), 2 complete and 35 partial responses, 4 stable disease and 5 progression. Median TTP was 12 months (2+-33+), median OS was 25 months (2+-34+), with a median follow-up of 12 months (2–34). Cumulative G3–4 toxicities by pts were: diarrhea 27%, mucositis 6%, hypertension 2%, hypertransaminasemy 2%, neutropenia 10%. No toxic deaths have occurred. Received-DI: CPT-11 84% of projected-DI, OHP 82%, 5-FU 85%, BEV 84%, per pt respectively. 17 pts (35%) had only liver metastasis and R0 resection was performed in 3 pts (18%). Conclusions: “Poker” combination with FIR-B/FOX schedule shows higher activity than triplet combinations. Thus it may be considered as the most active first line treatment of MCC.

No significant financial relationships to disclose.

The safety of dose-dense liposomal-encapsulated doxorubicin in association with docetaxel (MyTax) in breast cancer

Abstract #2157

Background: Liposomal-Encapsulated Doxorubicin (LED) shows equivalent efficacy, better cardiac tolerability at higher cumulative dose than conventional anthracyclines in breast cancer treatment.&#x2028; Methods: Sixteen pts were enrolled in a dose-finding study of LED (TLC-D99 Myocet ®) associated to Docetaxel (TXT). Twelve pts were treated with a fixed TXT dose (50 mg/m2) and TLC-D99 at three dose levels, 40-45-50 mg/m2, days 1 and 15 every 2 weeks using an intra- and inter-patient approach; four pts wrere treated at the TLC-D99 recommended dose (50 mg/m2). Cardiac monitoring of LVEF was performed every two cycles; Precursor Brain Natriuretic Peptide (proBNP) and cardiac Troponin (c-TnI) before and after 24 h chemotherapy was evaluated.&#x2028; Results: Breast cancer (BC) disease extension: metastatic (MBC), 8; locally advanced BC, 5; T2-T3 BC, 3. Previous chemotherapy: untreated, 11 pts; adjuvant, 5 pts. Enrolled pts for each dose-level: I, 7; II, 9; III, 14. Newly treated pts: I dose-level, 7; II dose-level, 3; III dose-level, 6. Valuable cycles for each dose-level in a total 77 cycles: I, 14; II, 21; III, 42. DLTs were observed in 3 pts, 21%, and 3 cycles, 4%: 2 cardiac, characterized by a 19% LVEF decrease and a symptomatic arrhythmia; one G4 hematologic resistant to G-CSF. DLTs for each dose-level by pts and cycles, respectively: I, 14% (1/7 pts) and 7% (1/14 cycles); II, no DLT in 9 pts and 21 cycles; III, 14% (2/14 pts) and 5% (2/42 cycles). Cumulative G3-4 toxicities by pts and cycles, respectively: cardiac arrhythmia 6% and 1,3%, cardiac general (symptomatic LVEF decrease), 6% and 1,3%; alopecia 81% and 65%; neutropenia resistant to G-CSF, 6% and 1,3%. Cardiac DLTs were observed in 2 elderly pts (&gt;65 y). The 2 cardiac DLTs were observed in 2 out of 3 pts with pre-existing diastolic dysfunction. No pathologic increase of c-TnI levels was detected. Seven pts showed increased pro-BNP after chemotherapy; 1 of these with increased pro-BNP after chemotherapy, persistent the day 1 of each subsequent chemotherapy showed a DLT;&#x2028; G2 toxicities by patients and cycles, respectively: asthenia 37% and 18%, stomatitis/mucositis 12% and 5%, nausea 31% and 12%. Median rDI of TLC-D99 was 25 mg/m2/w and TXT 25 mg/m2/w for pts, respectively. Preliminary efficacy in 16 assessable pts: LA-BC and MBC, 1 CR (pCR) 7 PR (OR 62%), 4 SD and 1 PD; T2-T3 BC, 2 PR and 1 SD.&#x2028; Conclusion: dose-dense TLC-D99/Docetaxel association can be safely recommended at the dose of 50 mg/m2 for each drug. Docetaxel intensification is ongoing.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2157.

[Health promotion and computer science in radiation protection]

An automatic system of clinical-diagnostic information has been applied to workers exposed to ionising radiation at the University of Naples Federico II with reference to the last 5 years. For every person exposed a computerized case sheet was elaborated recording clinical, biological, dosimetric and other preventive data. In the localized risk, capillaroscopic monitoring was used. This research has highlighted the role of medical surveillance in developing health promotion criteria and the planning of the interventions with the complete control of all data in real time.

Increased tolerability of bimonthly 12-hour timed flat infusion 5-fluorouracil/irinotecan regimen in advanced colorectal cancer: A dose-finding study

A dose-finding study was designed to determine the maximum tolerated dose (MTD) of a bimonthly 12-h (10:00 p.m to 10:00 a.m), timed flat infusion (TFI) of 5-fluorouracil (5-FU) plus irinotecan (CPT-11), without leucovorin (LV), for metastatic colorectal carcinoma (CRC). A total of 33 patients were treated. Seven dose levels included a fixed CPT-11 dose of 180 mg/m2 on days 1 and 15 (d(1,15)) and escalating doses of 5-FU 600-1200 mg/m2 on days 1-4 and 15-18 (d(1-4,15-18)). Dose-limiting toxicities (DLTs) were: grade 3-4 non-hematologic, grade 4 hematologic and any toxicity causing a more than a 2-week delay in treatment. The MTD was reached at the seventh dose level. DLTs were observed in 5/8 patients (63%): G3 diarrhea, 2 patients, associated with G3 mucositis in one instance; G4 neutropenia, 2 patients, associated with severe asthenia in 1 patient; G3 hand-foot syndrome, 1 patient. The recommended doses (RDs) were established at the sixth dose level: 5-FU, 1100 mg/m2/d(1-4,15-18); CPT-11 180 mg/m2/d(1,15) [5-FU and CPT-11 dose intensity (DI), 2200 and 90 mg/m2 per week (w), respectively]. At the recommended dose, the DLTs in 38 cycles were: mucositis, 2 cycles (5%); afebrile G4 neutropenia and hand-foot syndrome, 1 cycle (3%). In 24 assessable patients, the overall response rate was 37.5%. The present CPT-11/5-FU schedule is highly tolerable in an outpatient setting using the highest recommended 5-FU dose effective in advanced CRC.

From adjuvant to preventive breast cancer treatment: bridging the gap over troubled waters

Recently, chemoprevention trials have demonstrated the efficacy of preventive medical treatment (PMT) in reducing breast cancer (BC) detection rates in at-risk affected and unaffected women selected according to clinical and/or familial risk criteria, particularly with the use of tamoxifen (TAM). Major concerns limiting the routine use of TAM are the questionable benefit/risk ratio and poor patient compliance, which justify the studies undertaken to determine the efficacy of aromatase inhibitors (AIs) with respect to TAM. Issues such as therapy duration, impact on survival, incidence of side-effects and which subsets benefit most from treatment, still remain unsolved. Therefore, only ER+ BC patients are routinely subjected to PMT, independently of their BRCA1/2 status, using adjuvant hormonal therapy. More attention must be focused towards BRCA1/2 carriers as they are probably the women at highest risk of developing BC, in which available data remain controversial and in which hormone-therapy might be important. Hence, at-risk women (affected patients or unaffected women) should be carefully evaluated for inclusion into highly selected preventive clinical trials aimed at evaluating PMT independently of, or according to, BC predisposition status (unknown, positive or negative BRCA1/BRCA2 status) and with respect to menopausal status. BC patients, harboring a BRCA1/2 predisposition, may represent the best subset for extended adjuvant treatment, useful as PMT, simultaneously. Only the evolving differentiation of categories of at-risk women will allow physicians to discriminate PMT in a highly selective manner.

Timed flat infusion of 5-fluorouracil increases the tolerability of 5-fluorouracil/docetaxel regimen in metastatic breast cancer: a dose-finding study

A dose-finding study was undertaken to determine the maximum-tolerated dose, and the recommended dose of docetaxel in combination with 12-h timed (22:00–10:00) flat infusion of 5-fluorouracil (5-FU) in metastatic breast cancer patients. This schedule seems to reduce the occurrence of stomatitis of the docetaxel and infusional 5-FU regimen.

Reducing breast cancer incidence in familial breast cancer: overlooking the present panorama

Familial breast cancer, whether associated or not with particular other breast cancer features (male, early onset, bilateral breast cancer), determines a wide and variable risk of developing breast cancer in the 'unpatients' (unaffected individuals) of these families, particularly in those harboring a genetic predisposition. The antiestrogen tamoxifen has been proposed in different trials to prevent breast cancer in women at risk. The NSABP-P1 study demonstrated that tamoxifen drastically reduced (by approximately 50%) the incidence of breast cancer in women at risk selected according to the Gail score. The preventive effect was particularly consistent in postmenopausal women and in those showing familial breast cancer (three or more affected patients). BRCA1/BRCA2 (BRCA1/2) gene analysis in women accrued in the NSABP-P1 trial who developed breast cancer showed that tamoxifen chemoprevention reduced breast cancer incidence in BRCA2 carriers. Different chemoprevention trials are ongoing to compare different selective estrogen receptor modulators and aromatase inhibitors with tamoxifen. The Italian Consortium of Hereditary Breast Ovarian Cancer recently developed the Aromasin Prevention Study, a multicenter, double-blind, randomized, placebo-controlled phase III study evaluating the effect of the aromatase inhibitor exemestane for chemoprevention in postmenopausal women carriers of BRCA1/2 genetic predisposition. Women who are postmenopausal unaffected carriers of BRCA1/2 mutations will be selected by participating institutions and randomly assigned to receive either oral exemestane or oral placebo every day for 3 years in order to reduce the incidence of breast cancer. Genetic counseling and the detection of predisposing BRCA1/2 mutations are mandatory before accrual into the study. Signed informed consents for the performing of BRCA1 and BRCA2 genetic analysis and for enrollment into the study are required. Eligible women will be followed thereafter in order to evaluate the efficacy of exemestane in reducing the incidental rate of breast cancer in unaffected postmenopausal carriers of BRCA1/2 mutations.

Pelvic relapses in ovarian cancer. Role of CA-125, transvaginal ultrasound and color Doppler

From January 1995 to January 2001, 40 patients with epithelial ovarian cancer were treated at our Institution. Fourteen of these, with a clinical CR after surgery and platinum-based chemotherapy, were evaluated monthly by gynecological examination, Ca-125 RIA assay, pelvic ultrasound with transabdominal and transvaginal probe and color Doppler. Six pelvic relapses, from 1.5 to 3.0 cm, were detected by transvaginal ultrasound (US). They showed a rich neovascularization with low resistance, high flow, PI from 0.3 to 1.0 and RI < 0.5 in all cases. US did not reveal any sign of relapse in the remaining eight patients. In all cases of pelvic relapses ultrasonic signs of recurrence preceded the increase of Ca-125 by one to six months (average 3.8).

[Can analysis of the molecular status of the p53 gene contribute to improving the therapeutic strategy for breast carcinoma?]

The occurrence of mutations in the p53 tumor suppressor gene is a specific and recurring genetic event in solid tumors. P53 plays a pivotal role in multiple cellular processes such as cell growth control, DNA repair and programmed cell death. Genotoxic damage, also induced by chemotherapy or radiotherapy, induces p53 overexpression in order to control the rate of proliferating damaged cells, thus triggering the mismatch repair or apoptotic pathways. P53 inactivation determines a condition of genetic instability, justifying the subsequent susceptibility to acquire mutations of different other genes. P53 mutations are associated with worse prognosis and with chemo/radioresistance, due to the inability to trigger p53-dependent programmed cell death. Molecular diagnostic strategies show 32% p53 mutations in breast cancer. The analysis of the p53 gene performed by FAMA (Fluorescence Assisted Mismatch Analysis) in high-risk breast cancer patients with > or = 10 involved axillary nodes may help identify a subset of very high risk BC patients (vHR-BC) with poorer prognosis and a subset with better prognosis, potentially responsive to medical treatments. The accurate evaluation of the p53 status can predict prognosis and sensitivity to chemotherapy, thus representing the first step toward better definition of therapeutic strategies according to the molecular characterization of the individual patient.

P16 hypermethylation contributes to the characterization of gene inactivation profiles in primary gastric cancer

The objective of this study was to investigate the contribution of p16 inactivation in gastric cancer and to compare it with p53. A cohort of 34 primary GCs were analyzed for p16 mutations and transcriptional silencing of the gene due to hypermethylation of the promoter. SSCP analysis and direct sequencing of exons 1 and 2 of the p16 gene were performed to detect any structural alterations. The methylation specific PCR (MSP) assay was applied to reveal hypermethylation of the 'CpG' island in the regulatory region using specific primer pairs for methylated and unmethylated nucleotides after a chemical reaction converting cytosines into uracile when unmethylated. SSCP and direct sequencing analysis did not detect any p16 mutations. The MSP assay showed 4 MSP(+) variants (11.8%). Three MSP(+) were stage III-IV disease and 1 MSP(+) was detected in an early stage disease (IB). All MSP(+) were diffuse type adenocarcinomas. The MSP(+) samples were different from previously reported samples harboring p53 mutations in the same cohort. These data increase the number of gastric cancers showing alterations of either p53 or p16 to 29.4% (10/34). Functional inactivation by hypermethylation of the p16 locus and p53 mutations could play a significant, complementary role in the pathogenesis of sporadic gastric cancer.

Prophylactic options in patients with 5-fluorouracil-associated cardiotoxicity

At present, the various mechanisms involved in 5-fluorouracil (5-FU)-correlated cardiotoxicity remain to be elucidated and a universally accepted prophylaxis or treatment for this specific toxicity is not available. Although it may improve time to progression, survival and clinical benefit, a 5-FU-based regimen usually has to be discontinued if a patient experiences cardiotoxicity. Here, we describe our experience with three cases of 5-FU-associated cardiotoxicity. The angina-like pain that appeared approximately 95 h after beginning 5-FU therapy was apparently independent of the drug's administration modality. In the two patients receiving 5-FU 12-h flat continuous infusion from 22.00 to 10.00 h (5-FU 12-h c.i.) in combination with other drugs, the dose of 5-FU was reduced by 10-20% and patients received prophylactic transepidermal nitroglycerin. In the third patient, 5-FU administration modality was changed and prophylactic therapy was not given. By taking these precautions, the patients no longer complained of anginal pain and none of them discontinued chemotherapy.

Prognostic value of p53 molecular status in high-risk primary breast cancer

BACKGROUND

Mutations in the p53 gene are the most common genetic alterations in human primary breast carcinoma and these mutations are often associated with worse prognosis and chemo/radioresistance.

PATIENTS AND METHODS

The analysis of the p53 gene was performed by fluorescence-assisted mismatch analysis in 13 consecutive high-risk primary breast cancer (HR-BC) patients with 10 or more involved axillary nodes to evaluate its prognostic value.

RESULTS

Three p53 mutations (23%) and four allelic variants were detected. After a median follow-up of 52 months the HR-BC disease-free survival (DFS) was 51% and overall survival 79%. All patients harboring a p53 mutation (p53(mut)) relapsed within 10 months of the median DFS while 67% of those showing a wild-type p53 status (p53(wt)) survive disease-free at a median follow-up of 43 months. One p53(mut) patient is still alive while all the p53(wt) patients survive at 56 months median follow-up. Two out of the four p53(wt) relapsing breast cancer patients showed the Arg72Pro allelic variant; one of these died at 75 months.

CONCLUSIONS

p53 mutations may help identify a subset of very high risk breast cancer patients (vHR-BC) with worse prognosis.

Hypersensitivity reaction to carboplatin: successful resolution by replacement with cisplatin

Hypersensitivity reactions caused by carboplatin rarely occur. These reactions can cause lethal complications and make subsequent therapeutic approaches difficult. To date, only a few cases of successful resolution of hypersensitivity by replacement of carboplatin with cisplatin have been reported. We report on a patient with serous papillary extra-ovarian peritoneal carcinoma who developed a hypersensitivity reaction after the 10th weekly administration of carboplatin. Two weeks after reaction, intradermal skin testing with paclitaxel, carboplatin, cisplatin, and mannitol showed intense reaction only to carboplatin. On the basis of these results, the patient was changed to a chemotherapy with cisplatin and paclitaxel. A further eight courses of chemotherapy were administered without evidence of hypersensitivity reactions. Carboplatin seems to be successfully replaceable by cisplatin in case of hypersensitivity reactions.

Cerebral metastasis from ovarian cancer treated with a multidisciplinary approach. Case report and review of literature

Brain metastases from ovarian cancer are rare. A review of five autopsy studies reported brain metastases in 4% of 712 patients who died with a diagnosis of ovarian cancer. The prognosis is very poor and a consensus on the standard treatment is not available. We report the case of a patient who developed a solitary brain metastasis as single evidence of relapse, 26 months after the first diagnosis of ovarian cancer. A temporo-parietal craniotomy with excision of the mass and whole brain radiotherapy were performed. The patient is free of disease five months after radiotherapy completion. Also in patients suffering from neoplasms that rarely metastasize to CNS, a careful clinical examination may help to diagnose uncommon sites of disease relapse.

P16 hypermethylation contributes to the characterization of gene inactivation profiles in primary gastric cancer

The objective of this study was to investigate the contribution of p16 inactivation in gastric cancer and to compare it with p53. A cohort of 34 primary GCs were analyzed for p16 mutations and transcriptional silencing of the gene due to hypermethylation of the promoter. SSCP analysis and direct sequencing of exons 1 and 2 of the p16 gene were performed to detect any structural alterations. The methylation specific PCR (MSP) assay was applied to reveal hypermethylation of the 'CpG' island in the regulatory region using specific primer pairs for methylated and unmethylated nucleotides after a chemical reaction converting cytosines into uracile when unmethylated. SSCP and direct sequencing analysis did not detect any p16 mutations. The MSP assay showed 4 MSP(+) variants (11.8%). Three MSP(+) were stage III-IV disease and 1 MSP(+) was detected in an early stage disease (IB). All MSP(+) were diffuse type adenocarcinomas. The MSP(+) samples were different from previously reported samples harboring p53 mutations in the same cohort. These data increase the number of gastric cancers showing alterations of either p53 or p16 to 29.4% (10/34). Functional inactivation by hypermethylation of the p16 locus and p53 mutations could play a significant, complementary role in the pathogenesis of sporadic gastric cancer.

Surgical treatment of invasive carcinoma of the vulva. Our experience

OBJECTIVE

The purpose of this study was to investigate the clinical findings, treatment and outcome of patients with vulvar carcinoma in the L'Aquila area.

METHODS

Fifteen cases of vulvar carcinoma seen between September 1991 and December 1999 at the Department of Obstetrics and Gynecology of the University of L'Aquila were reviewed. Clinical, pathologic, surgical and follow-up data were collected from patient records. Mean age at diagnosis was 66.4 years. All patients were evaluated through a careful medical history and physical examination, vulvoscopy, abdomino-pelvic CT or MR, urethrocystoscopy, rectocolonscopy and SCC, and CEA determination. Radical surgery included six patients treated by the Taussig-Way operation. Modified radical surgery accounted for nine patients treated by the Byron three-incision approach.

RESULTS

The major early complication was groin wound breakdown which occurred in four cases. The major late complication was chronic leg edema which was reported in six patients. The average number of nodes removed per patient was 19.5. Seven patients (46.7%) had a T2N0M0 pathologic stage, four (26.7%) were T2N1M0, four (26.7%) T1N0M0. Five patients died of local and distant recurrences within 37 months after surgical treatment; ten patients are alive, nine are apparently free from disease whereas one presented local and systemic recurrence within 18 months after surgery.

CONCLUSIONS

Vulvar carcinoma predominantly affects older women. Most patients in our series (11/15) had tumors more than 2 cm in diameter. Although the vulva is an external organ and early detection should be achieved, many patients presented with extensive primary lesions due to both patient and physician delay. Stage of disease, tumor size, and nodal metastases are potential prognostic factors useful in selecting patients for a more conservative surgical approach.

Cervical sarcoma botryoides treated with conservative surgery and adjuvant chemotherapy: a case report

A case of cervical sarcoma botryoides treated with conservative surgery and adjuvant monochemotherapy is presented.

[Injectable progesterone in hormone replacement therapy in menopause]

PURPOSE

To evaluate activity and tolerability of intramuscular administration of 17-alpha-hydroxyprogesterone caproate (Lentogest-Amsa) in hormone replacement therapy in menopause.

PATIENTS AND METHODS

Intramuscular slow releasing 17-alpha-hydroxyprogesterone caproate was given to 30 postmenopausal women. Patients were divided into two groups according to the number of monthly doses (1 or 2).

RESULTS

In both groups of patients a regular monthly bleeding was obtained. Echographic assessment did not show abnormal endometrial thickness.

CONCLUSIONS

The results of this study have pointed out the efficacy of intramuscular progesterone-caproate administration with a better compliance in the single dose group.

[Hormone substitution therapy during menopause. Increase of compliance]

BACKGROUND

Hormonal replacement therapy (HRT) is always of major employ in the practice. Unfortunately, a high percentage of women interrupt therapy after a few months.

METHODS

Two hundred menopausal women with intact uterus were studied. During the first consultation, they received an informative booklet regarding the menopause, without any verbal information. During the second visit, the gynaecologist discussed with the patient the information acquired and prescribed the HRT (50 mcg/die of transdermal estradiol, as continuous therapy, and 5 mg medroxyprogesterone acetate/os for 10 days/months) to those who required it. The compliance to treatment at 3, 6 and 12 months has been recorded.

RESULTS

Of the 200 women studied, 153 referred to have read the informative booklet: 112 requested further informations to their family doctor; 97 discussed the contents with the partner; 130 expected HRT. The 3 months, 6 months and 12 months compliance has been of 110 (84%), 97 (74%) and 68 women (52%) respectively. Causes of drop out: breast tension (12%); water retention and/or increase of weight (20%); headache (7%); vaginal blood loss (22%); others [fear of cancer, etc.] (54%).

CONCLUSIONS

According to personal opinion, three factors may condition the compliance to the HRT: 1) circumstantial information, not only verbal before the onset of therapy; 2) treatment protocols with low incidence of side effects; 3) frequent follow-up.

[Colposcopic monitoring of primary chemotherapy in patients with locally advanced cancer of the uterine cervix]

OBJECTIVE

To evaluate colposcopy in the monitoring of patients affected by locally advanced cervix cancer treated with primary chemotherapy.

MATERIALS AND METHODS

Eight patients (42-54 years old) affected by squamous cervical cancer locally advanced (stage FIGO IIa "bulky"/IIb/III) were treated with primary chemotherapy (cisplatin 50 mg/m2 vincristin 1 mg/m2 bleomicin 30 UI in 24 hours continuous infusion q 7 days for 3 cycles). Colposcopy was performed before chemotherapy, after the second cycle and at the end of chemotherapy.

RESULTS

Two pathological complete responses, 5 partial responses and one case of stable disease were observed. Patients with complete and partial response were treated with radical hysterectomy. In responding patients we observed a typical sequence of colposcopic findings. Regression of distinctive malignancy feature, reduction of atypical vessels, gradual disappearance of peripheral lesions and centripetal reepilization of the cervix were sequentially registered. At the end of treatment the cervix appeared with a colposcopy imaging as well as a centripetal squamous complete or incomplete metaplasia, open--for most part--glandular exit and weak acid-iodic positivity.

CONCLUSION

In responding patients we observed a typical sequence of colposcopy finding, useful in order to evaluate the effects of chemotherapy and to programme the surgical approach.

[Malignant gynecologic neoplasms during menopause. Authors' experience]

From January 1991 to December 1993 409 post-menopausal women were observed at the Center for the Study of Climateric Disorders of the Department of Obstetrics and Gynecology of the University of L'Aquila. The aim of the study was to evaluate the incidence of gynecologic neoplasm among this group of women. A total of 48 women at risk for malignant tumors were detected. The relationship between the climateric age and the oncologic risk is discussed.

[Bacterial vaginosis during chemotherapy for gynecological neoplasms. A therapeutic proposal]

Bacterial vaginosis (BV) is a well characterized disease, defined Amsel's criteria, whose incidence is significantly increased during chemotherapy for gynecologic malignancies, as previously reported by the authors. Nine patients out of 14 (64%) who were receiving adjuvant chemotherapy for gynecologic tumors showed a clinical and laboratory evidence of bacterial vaginosis and were treated with cetyltrimethilammonium naproxenate vaginal douches. Results were analyzed up to the completion of oncologic chemotherapy: a high efficacy and tolerability for the topical treatment was demonstrated in all cases.

"Venous hemofiltration associated with loco-regional chemotherapy in the treatment of patients with liver neoplasm"

In order to evaluate the possibility to administer high FUDR doses, 52 patients with liver metastases were treated with loco-regional chemotherapy associated with venous hemofiltration. The clinical and pharmacological results of this approach are discussed.

[Synchronous associations of tumors in the pelvic organs of the female genital tract]

The Authors report their findings concerning the synchronous associations of tumours involving pelvic organs in the female genital tract observed at the Gynecological Clinic, Aquila. From January 1980 to December 1991, 9 cases (4.28%) of synchronous tumours were found in a total of 210 cases of womb, ovary and vagina tumours. The paper examines the clinical problems and questions of anatomopathological characterisation raised by these associations.

[Effects of estradiol on in vitro cultures of human fibroblasts]

This paper assesses the effect of estradiol on the in vitro growth of fibroblast taken from human breast skin. It was observed that estrogens stimulate the proliferation of phenotypically adult fibroblasts; that there is a threshold increase of hormonal concentration which can trigger off this process; and that the size of the single dose is more important than the number of doses of hormone received.

[Use of an animal model in the study of changes in erythrocyte deformability caused by breast cancer]

The paper reports the results of a study to assess the effects on erythrocytic deformability of the induction of hepatic metastases of breast cancer in an animal model. The results demonstrate a reduced level of erythrocytic deformability induced by tumor development.

[Cervical maturation. Physiologic aspects and pharmacologic implications]

The latest theories on cervical maturation and the techniques of pharmacological induction of labour are summarised. The role of the prostaglandins is particularly stressed both from the physiological viewpoint and as drugs of choice for effective pharmacological induction of uterine cervix. Finally, the personal clinical protocol for the induction and management of labour is reviewed.