Platinum-containing regimens for metastatic breast cancer

BACKGROUND

Studies have reported high tumour response rates for platinum-containing regimens in the treatment of women with metastatic breast cancer. Most of these studies were conducted prior to the 'intrinsic subtype' era, and did not specifically focus on metastatic triple-negative breast cancers (mTNBCs).

OBJECTIVES

To identify and review the evidence from randomised trials comparing platinum-containing chemotherapy regimens with regimens not containing platinum in the management of women with metastatic breast cancer.

SEARCH METHODS

For this review update, we searched the Cochrane Breast Cancer Group's Specialised Register, CENTRAL, MEDLINE, Embase, the World Health Organization's International Clinical Trials Registry Platform and ClinicalTrials.gov on 28 May 2015. We identified further potentially relevant studies from handsearching references of previous trials, systematic reviews, and meta-analyses. Prior to this review update, the most recent search for studies was conducted in May 2003 for the original 2004 review.

SELECTION CRITERIA

Randomised trials comparing platinum-containing chemotherapy regimens with regimens not containing platinum in women with metastatic breast cancer.

DATA COLLECTION AND ANALYSIS

At least two independent reviewers assessed studies for eligibility and quality, and extracted all relevant data from each study. Hazard ratios (HRs) were derived for time-to-event outcomes, where possible, and fixed-effect models were used for meta-analyses. Objective tumour response rates (OTRRs) and toxicities were analysed as binary (dichotomous) outcomes with risk ratios (RRs) used as measures of effects. Quality of life data were extracted where available. GRADE was used to rate the quality of evidence for survival and tumour response outcomes at the level of subgroups selected and unselected for mTNBC, and for toxicity outcomes based on combining data from selected and unselected populations.

MAIN RESULTS

This update includes 15 new eligible treatment-comparisons from 12 studies. In total, 28 treatment-comparisons, involving 4418 women, from 24 studies are now included in one or more meta-analyses. Of the 28 treatment-comparisons, 19 and 16 had published or provided extractable time-to-event data on overall survival (OS) or progression-free survival/time to progression (PFS/TTP), respectively. All 28 treatment-comparisons provided OTRR data that could be included in meta-analyses. Most women recruited to the studies were not selected on the basis of mTNBC status.In a subgroup of three treatment-comparisons assessing women with mTNBC, platinum-containing regimens may have provided a survival benefit (HR 0.75, 95% CI 0.57 to 1.00; low-quality evidence). In women unselected for intrinsic subtypes such as mTNBC, there was little or no effect on survival (HR 1.01, 95% CI 0.92 to 1.12; high-quality evidence). This effect was similar to the combined analysis of survival data for both populations (HR 0.98, 95% CI 0.89 to 1.07; I² =39%, 1868 deaths, 2922 women; 19 trials). The difference in treatment effects between mTNBC women compared with unselected women was of borderline statistical significance (P = 0.05).Data from three treatment-comparisons with mTNBC participants showed that platinum regimens may improve PFS/TTP (HR 0.59, 95% CI 0.49 to 0.72; low-quality evidence). Thirteen treatment-comparisons of unselected metastatic participants showed that there was probably a small PFS/TTP benefit for platinum recipients, although the confidence interval included no difference (HR 0.92, 95% CI 0.84 to 1.01; moderate-quality evidence). Combined analysis of data from an estimated 1772 women who progressed or died out of 2136 women selected or unselected for mTNBC indicated that platinum-containing regimens improved PFS/TTP (HR 0.85, 95% CI 0.78 to 0.93). There was marked evidence of heterogeneity (P = 0.0004; I² = 63%). The larger treatment benefit in mTNBC women compared with unselected women was statistically significant (P < 0.0001).There was low-quality evidence of better tumour response in both subgroups of women with mTNBC and unselected women (RR 1.33, 95% CI 1.13 to 1.56; RR 1.11, 95% CI 1.04 to 1.19, respectively). Combined analysis of both populations was closer to the effect in unselected women (RR 1.15, 95% CI 1.08 to 1.22; 4130 women). There was considerable evidence of heterogeneity (P < 0.0001; I² = 64%), which may reflect between-study differences and general difficulties in assessing response, as well as the varying potencies of the comparators.Compared with women receiving non-platinum regimens: rates of grade 3 and 4 nausea/vomiting were probably higher among women receiving cisplatin- (RR 2.65, 95% CI 2.10 to 3.34; 1731 women; moderate-quality evidence) but the effect from carboplatin-containing regimens was less certain (RR 0.77, 95% CI 0.47 to 1.26; 1441 women; moderate-quality evidence); rates of grade 3 and 4 anaemia were higher among women receiving cisplatin- (RR 3.72, 95% CI 2.36 to 5.88; 1644 women; high-quality evidence) and carboplatin-containing regimens (RR 1.72, 95% CI 1.10 to 2.70; 1441 women; high-quality evidence); rates of grade 3 and 4 hair loss (RR 1.41, 95% CI 1.26 to 1.58; 1452 women; high-quality evidence) and leukopenia (RR 1.38, 95% CI 1.21 to 1.57; 3176 women; moderate-quality evidence) were higher among women receiving platinum-containing regimens (regardless of platinum agent).

AUTHORS' CONCLUSIONS

In women with metastatic breast cancer who do not have triple-negative disease, there is high-quality evidence of little or no survival benefit and excess toxicity from platinum-based regimens. There is preliminary low-quality evidence of a moderate survival benefit from platinum-based regimens for women with mTNBC. Further randomised trials of platinum-based regimens in this subpopulation of women with metastatic breast cancer are required.

The effect of tennis racket string vibration dampers on racket handle vibrations and discomfort following impacts

In this study, we evaluated the effect of the use of tennis racket string vibration dampers on racket handle vibrations, and perceptions of hand and arm discomfort experienced by tennis players owing to stationary racket impacts. Twenty tennis players (10 males, 10 females) aged 18-29 years volunteered for the study. Two different racket models were impacted at the geometric centre of the racket face and 100 mm distal to the centre both with and without string vibration dampers in place. The participants could neither see nor hear the impacts, and they indicated their discomfort immediately after each impact using a visual analogue scale. An analysis of variance (2 x 2 x 2 factorial) was performed on the scaled discomfort ratings with the factors damping condition, racket type and impact location. No significant differences in discomfort ratings between damped and undamped impacts or between the two racket types were found. Also, central impacts were found to be more comfortable than impacts 100 mm distal to the centre (P< 0.05). There were no significant interaction effects. Vibration traces from an accelerometer mounted on the racket handle revealed that string vibration dampers quickly absorbed high-frequency string vibration without attenuating the lower-frequency frame vibration. In conclusion, we found no evidence to support the contention that string vibration dampers reduce hand and arm impact discomfort.

Cross-femoral venous bypass in combination with tumor resection

The cross-femoral venous bypass procedure (also known as the Palma/Dale procedure) was introduced for unilateral iliac or common femoral vein occlusions resulting in chronic deep venous insufficiency. We have utilized the procedure successfully in a patient who required extensive pelvic tumor resection involving sacrifice of pelvic venous collateral channels and unilateral ligation of external, internal, and common iliac veins. The case report and review of the literature are presented.

Sonographic evaluation of renal artery aneurysm in childhood

We report a child presenting with renovascular hypertension and sonographic evidence of a renal artery aneurysm (RAA). The diagnosis of RAA was made sonographically by demonstrating vascular flow in an aneurysmal segment adjacent to but continuous with the right renal artery and externally compressing the inferior vena cava. Comparison of the sonographic studies and an abdominal angiogram illustrate the sensitivity of sonography in diagnosing this condition. We suggest that with renal doppler sonography, RAA may be diagnosed less invasively and possibly with greater frequency yet believe that the gold standard of angiography is necessary prior to surgical intervention.

Percutaneous placement of a hepatic vein stent in the treatment of Budd-Chiari syndrome

The authors describe the first reported use, to their knowledge, of an intravascular stent to relieve hepatic vein stenosis causing the Budd-Chiari syndrome. A patient with severe stenosis of the left hepatic vein is described. Multiple balloon angioplasty procedures were performed over a period of several months and provided only transient relief of symptoms. As an alternative to surgical management, an intravascular stent was placed, with complete resolution of symptoms. Intravascular stent placement may play an important role in treatment of the Budd-Chiari syndrome.

Inferior vena caval filters in heart transplant recipients with perioperative deep vein thromboses

Heart transplant recipients may constitute a high-risk group for pulmonary embolism and subsequent complications. We present the cases of two patients who underwent prophylactic filter insertion after deep venous thrombosis developed perioperatively and discuss our rationale for this approach.

True tibial artery aneurysms: case report and literature review

True tibial artery aneurysms are rare lesions. They may manifest themselves clinically either as a painful leg mass or as evidence of ischemic changes in the foot. Asymptomatic lesions may be found incidentally during arteriography. The need for surgical intervention should be individualized depending on the presentation; the type of surgical intervention is based on coexistent tibial artery anatomy. The present report describes a patient with a true tibial artery aneurysm. Clinical presentation, radiographic findings, and surgical management are described.

How accurate are ventilation-perfusion scans for pulmonary embolism?

To evaluate the accuracy of ventilation-perfusion scanning in the diagnosis of pulmonary embolism, the pulmonary arteriograms of 55 patients suspected of pulmonary embolism were compared with their ventilation-perfusion scans. The clinical presentation was consistent for the diagnosis of pulmonary emboli in all 55 patients. The scans were divided into the following four categories according to standard guidelines: normal, low, intermediate, and high probability. Three patients had normal scans confirmed by arteriography; 34 patients had high-probability scans, but only 22 (65 percent) were positive at arteriography. The remaining 18 patients had low or intermediate-probability scans (9 patients each), 5 of whom (28 percent) were positive at angiography (sensitivity 82 percent, specificity 57 percent). This study demonstrates the inaccuracy of ventilation-perfusion scanning for the evaluation of pulmonary embolus and may represent the variability of interpretation at individual institutions. Perhaps each institution may need to compare the results of ventilation-perfusion scanning and angiography to optimally select and treat patients.

Magnetic resonance imaging of the pediatric spine

The authors conclude that MRI is the imaging mode of choice for the evaluation of extradural and intramedullary tumors and for the screening of all children with suspected spinal pathology.

Use of a balloon-tipped perfusion catheter for renal preservation during suprarenal abdominal aortic operations

Two cases are presented that illustrate the use of the Pruitt-Inahara vascular shunt to avoid renal failure during suprarenal aortic reconstruction. Previously reported methods of renal preservation are briefly reviewed, and the advantages of a balloon-tipped perfusion catheter over previously reported techniques are presented.

Defective binding of the third component of complement (C3) to Streptococcus pneumoniae in multiple myeloma

Patients with multiple myeloma (MM) are at an increased risk for infections with bacteria that require opsonization with complement. Because Streptococcus pneumoniae is the most frequently encountered pathogen in these patients, we investigated the ability of serum from patients with MM to mediate the binding of C3b, the major opsonin of the complement system, to S. pneumoniae. S. pneumoniae types 3, 14, and 25 were chosen for study, since S. pneumoniae type 3 activates primarily the classical complement pathway (CCP), type 25 primarily the alternative complement pathway (ACP), and type 14 both pathways. S. pneumoniae were treated with normal serum or serum from 17 patients with MM, and the bound C3b was quantified with fluorescein-conjugated anti-C3 in a spectrophotofluorometric assay. Despite normal or elevated serum concentrations of C3, total hemolytic complement, and C-reactive protein in all of the MM sera, factor B in 16/17 such sera, and C4 in 14/17 MM sera studied, all 17 sera demonstrated a defect in C3b binding to type 3 (32.7% +/- 6% of normal). In addition, serum from 15/17 patients bound decreased amounts of C3b to types 14 (39.6% +/- 8%) and 25 (52.2% +/- 8%). Mixing normal serum with MM serum restored MM C3b binding activity to all three S. pneumoniae types, suggesting that the defect was related to a deficiency rather than an inhibitor of C3 activation. Although MM patients are unable to produce specific antibodies to bacterial antigens, the addition of anti-S. pneumoniae antibodies to MM serum did not enhance C3b binding to any of the S. pneumoniae types. However, when S. pneumoniae were opsonized in a mixture of MM serum and C3-depleted normal serum, C3b binding was restored to all three S. pneumoniae types, demonstrating that MM C3 functions normally in the presence of other normal serum factors. In the present studies, the MM C3b binding defect appeared to correlate with the incidence of S. pneumoniae infections. Serum from patients with a history of an S. pneumoniae infection bound significantly less C3 (20.5% +/- 4%) than those study patients without a history of an S. pneumoniae infection (55.8% +/- 8%) (p less than 0.0025). Thus, MM serum has a defect in the activation of C3, and this may contribute to the increased susceptibility of MM patients to S. pneumoniae infections.

Considerations in extrathoracic reconstruction for disease of the branches of the aortic arch

The effectiveness and decreased morbidity and mortality of extrathoracic reconstruction for disease of branches of the aortic arch has been reported by several workers; however, there has been relatively little discussion in the literature in regard to designing the operation to correct the pathophysiologic process of the disease (embolism versus flow reduction). The technique of reconstruction should be selected with regard to a patient's symptoms and arteriographic findings, with embolic phenomena more likely in patients with cerebral hemispheric symptoms and arteriographic stenosis rather than total occlusion. Simple bypass for suspected proximal embolic disease is inadequate.

Graft replacement of aneurysm in descending thoracic aorta: results without bypass or shunting

During the 24-year period from 1956 to 1980, 148 patients with aneurysms confined to the thoracic aortic segment, bounded above by the left subclavian artery and below the diaphragm, were treated with replacement therapy. From 1956 to 1967, 36 patients were treated by use of temporary bypass or shunts which carried a 6% incidence of paraplegia and a mortality rate of 22%. From 1962 to 1980, 112 patients were treated without shunts or bypass; this report is concerned with the latter cases. The incidence of paraplegia and the survival rate in this group were 0.9% and 91%, respectively. There were 89 men and 25 women in the series whose ages ranged from 22 to 87 years with an average age of 61. All types of aneurysms were represented; however, arteriosclerosis and dissection were the most common causes. The extent of aneurysm was variable, but most of the descending thoracic aorta was involved in more than half the cases. Associated diseases were present in 77% of cases. Operation consisted of aneurysmal replacement using inclusion technique with cardiac hemodynamics controlled by vasodilators and fluid replacement. During the past 4 years, proximal blood pressure has been controlled with nitroprusside. Cardiovascular hemodynamics, blood gases, electrolytes, and plasma osmolarity were monitored extensively and frequently to achieve the most desirable physiologic response to aortic clamping and operation. During this time 69 patients were treated. There were four (6%) deaths. None developed paraplegia or renal failure. Concomitant subclavian artery clamping was employed in 34 of these patients and in 22 additional patients with distal arch lesions. None in either group developed paraplegia. This indicated the safety of temporary subclavian artery occlusion. Death, both early and late, was due to a number of causes, but rupture of another aneurysm was the most common. This emphasizes the value of concomitant operation in patients with multiple aneurysms and careful follow-up in all patients.