Tumori Journal

The aim of this study was to investigate the efficacy of postoperative locoregional radiotherapy in patients with T1-T2 breast cancer and four or more positive axillary lymph nodes submitted to mastectomy or breast-conserving surgery followed by standard-dose or high-dose adjuvant chemotherapy. The incidence of locoregional relapses and the survival correlated with the number of positive nodes were recorded for each treatment arm.

From August 1992 to August 1999 86 breast cancer patients (median age, 54 years, T1-T2, N+ >4) submitted to surgery were treated. Sixty-three patients received standard-dose chemotherapy while 23 patients with 10 or more positive nodes received high-dose chemotherapy. After four courses of standard-dose anthracycline-based chemotherapy peripheral blood stem cells were mobilized with cyclophosphamide (7g/m²) and G-CSF (10-16 μg/kg/day/sc). High-dose chemotherapy consisted of etoposide 1000 mg/m², thiotepa 500 mg/m² and carboplatin 800 mg/m². Hormone receptor-positive patients underwent hormone therapy. Following chemotherapy all 86 patients were given conventional radiotherapy to the breast or the chest wall and the supraclavicular fossa. The high-dose subgroup received radiotherapy to the internal mammary nodes ± axilla. Results: The median follow-up from the start of radiotherapy was 36.5 months. Locoregional relapses occurred in nine patients (10.4%); in four of them they were isolated (4.6%). Local relapses were four (4.6%) and regional relapses six (6.9%). Twenty-five patients (29%) had distant metastases. The five-year and eight-year overall actuarial survival rates were 82.6% ± 4.8 and 60.1% ± 8.8, respectively. No statistical differences were found when the number of positive nodes or the type of treatment of N+ 10 patients was included in the analysis.

Breast cancer patients with four or more positive axillary lymph nodes are at high risk of developing locoregional and distant relapses. The results reported here demonstrate the efficacy of radiotherapy in the reduction of locoregional failure; no differences in survival and locoregional control in relation to treatment arm and number of positive nodes were found.

Multiple myeloma cells increase Th3 cytokine response by secreting TGF-β, which causes defective Th1 and Th2 cytokine responses. Therefore, a significant suppression of the immune system is seen in multiple myeloma. Interferon-α (IFN-α) is used in the treatment of multiple myeloma due to its immunomodulatory and anti-tumoral effects. We attempted to define the characteristics of immune cytokine responses and the effects of IFN-α-2a on the immune response in multiple myeloma.

Fifteen patients with multiple myeloma and 15 healthy controls were enrolled. IFN-α-2a, 3 million units/day x 3 times/week, was administered subcutaneously to the patients for 2 weeks. Cytokines (TGF-β, IL-1, IL-2, IL-4, IL-10, IFN-γ) were assessed by the ELISA method in sera of the patients in pretreatment and posttreatment periods and in the sera of the controls.

IL-2 and IL-4 levels in patients, before IFN-α-2a, were lower than the controls, whereas TGF-β levels were higher than the controls. In other words, Th3 cytokine response was increased and Th1 and Th2 cytokine responses were decreased in patients. A short course of IFN-α-2a increased IL-2 levels.

These findings suggest IFN-α-2a may enhance nonTh3 cytokine responses in multiple myeloma patients.

Venous thromboembolism (VTE) is a quite common complication in acute leukemia, although its real incidence is unknown. The best treatment of this complication is still a matter of debate due to the very high risk of hemorrhage in this group of patients.

From December 2000 to December 2002 four Caucasian patients with acute leukemia developed VTE complications. The patients were three men and one woman, mean age 55.7 years (range, 27-77). Two patients with acute lymphoid leukemia (L1 and L2 according to the FAB classification) developed deep venous thrombosis during the administration of chemotherapy; one patient with acute myeloid leukemia (AML, M2 according to the FAB classification) had pulmonary thromboembolism at diagnosis, while another AML patient (M4 according to FAB) showed deep venous thrombosis as the first symptom of leukemia. The clinical diagnosis of symptomatic VTE was confirmed by objective imaging procedures including lower limb venous color Doppler imaging in all cases and a ventilation-perfusion lung scan in one case. All patients were treated with enoxaparin 100 IU/kg subcutaneously twice daily for one month, followed by 150 IU/kg once daily for at least five months. When the platelet count was below 20,000 × 10⁹/L, the dose was reduced by 50%.

During antithrombotic treatment neither VTE recurrences nor hemorrhagic complications or heparin-induced thrombocytopenia occurred. The platelet count at the beginning of enoxaparin treatment was very low (mean, 55,750 × 10⁹/L; range, 12,000-121,000 × 10⁹/L) and treatment did not affect platelet recovery.

Enoxaparin proved to be efficacious and safe in the management of deep venous thrombosis with or without pulmonary embolism in patients affected by acute leukemia. Enoxaparin cured acute venous thrombosis, prevented recurrences and did not cause any hemorrhagic complications despite prolonged severe thrombocytopenia.

There is no comprehensive study that compares the different usage strategies of recombinant human erythropoietin (rHuEPO) in platinum-induced anemia. In order to clarify this issue, we conducted a prospective clinical study.

Seventy-seven patients were studied in three main groups. Group 1 (n = 17) consisted of cancer patients without anemia. These patients received rHuEPO starting from the first chemotherapy cycle. Group 2 (n = 26) consisted of patients whose hemoglobin (Hb) values decreased by at least 1 g/dL after the first cycle of chemotherapy. Group 3 (n = 34) consisted of patients whose Hb values dropped below 10.5 g/dL after the second chemotherapy cycle. Groups 2 and 3 were each divided into two subgroups. In groups 1, 2A and 3A rHuEPO (5000 U/day subcutaneously three times a week) treatment was continued until three weeks after the completion of chemotherapy. In groups 2B and 3B, rHuEPO was given for 12 weeks only.

There were no prominent differences between the Hb values of these groups throughout the chemotherapy cycles. Transfusion rates and the number of patients who became anemic were also not different between groups.

No rHuEPO usage strategies are superior to others in terms of Hb levels and transfusion requirements. The decision as to when rHuEPO is to be added to platinum-containing therapy should be tailored to the health conditions of individual patients.

Amputation surgery in pediatric patients suffering from malignant tumors is less common than in the past, but has a great emotional impact on patients and their families as well as on the medical team. Studies addressing the psychological aspects of limb amputation in childhood cancer are still relatively limited, and the results have sometimes been contradictory.

At the Pediatric Oncology Unit of the Istituto Nazionale Tumori of Milan psychological support was provided to candidates for amputation and their families, involving medical oncologists, a clinical psychologist, and social assistants. Twenty-two patients were analyzed and 16 underwent mutilating surgery.

Different emotional reactions were observed. Surgery proved to be easier to accept when the tumor caused pain and functional loss. Specialist medical psychological support was needed in case of defense mechanisms (eg, splitting and projection) and depressive reactions evolving into isolation or intolerance.

The reported experience could be helpful in providing adequate support to children with tumors requiring mutilating surgery.

Gynecomastia is an abnormal increase in the volume of the male breast that is generally considered to be due to an increased estrogen/androgen ratio. Pathological causes of gynecomastia include organic diseases and therapy, such as the administration of estrogens and antiandrogens, which alter the ratio of circulating hormones. Hormone therapy for prostate cancer is generally well tolerated but often accompanied by the occurrence of gynecomastia and breast pain or tenderness. The increased use of antiandrogens as monotherapy is leading to an increase in the number of patients affected by gynecomastia. Treatments are available to alleviate or prevent the development of gynecomastia, including medical treatment with antiestrogens and aromatase inhibitors. Alternatively, mastectomy with excision of the gland, liposuction or an association of the two techniques have proved to be effective. Radiation therapy may provide effective relief from the breast pain associated with gynecomastia. In this paper we show the good results of mastectomy performed with a lower semicircular periareolar incision in men suffering from gynecomastia due to antiandrogen therapy for inoperable prostate cancer. In addition, we present a review of the various techniques used for the treatment of gynecomastia.

During the period from September 1998 to May 2001, 10 patients receiving hormone treatment for metastatic or inoperable prostatic cancer were selected for the study if they had breast pain and bilateral gynecomastia. Five of these patients had been offered prophylactic radiotherapy before treatment but refused, while the remaining five patients had refused radiotherapy after hormone treatment. These patients were therefore given the option of surgical treatment. Before surgery all patients underwent clinical and ultrasound examination of the breast. All surgical samples were examinated histopathologically. During follow-up clinical examinations were carried out one week, one month, six months, one year and two years after surgery.

The results were satisfactory in all patients especially from an aesthetic point of view. Moreover, breast pain disappeared about one week after surgery. After a follow-up of 6-36 months (average, 22.8 months) no recurrences were observed. Only a few immediate postoperative complications were recorded (hematoma in one case and seroma in another). Histological examination of the excised glands showed fibrosclerotic tissue and a small amount of fat.

Surgical liposuction can be considered an effective treatment for gynecomastia, in particular in the very early stages because the breast becomes irreversibly fibrous as the disease progresses. This surgical technique is simple and effective and is therefore to be considered favorable, especially because of the very short hospitalization and the absence of complications.

To add a further contribution to the literature supporting the relationship between previous head trauma and development of glioma.

We report on four patients who developed brain gliomas in the scar of an old brain injury.

All cases fulfilled the widely established criteria for brain tumors of traumatic origin. In all of our cases there was radiological evidence of absence of tumor at the time of the injury.

We believe that in specific cases it is reasonable to acknowledge an etiological association between a severe head trauma and the development of a glioma. This assumption is further sustained if there is radiological and surgical documentation of the absence of neoplasia at the moment of the trauma.

Gastric cancer is associated with high mortality. Although the liver is a common site of metastases in this tumor, the experience with liver-directed therapies is limited.

We report a single-center experience involving four patients with liver metastases from gastric cancer treated by hepatic arterial infusion (HAI). In addition, we performed a search for reports on HAI in gastric cancer metastatic to the liver and used the studies with data on survival of individual patients for a pooled analysis.

Among three valuable patients, one had a complete response, one had stable disease and one had progressive disease. The patient with complete response is still alive 41 months after the diagnosis of liver metastases, while the other patients died 6, 22 and 31 months after the diagnosis. Objective responses were observed in 48% of the 25 patients in the pooled analysis. Objective response and limited hepatic involvement were independent predictors of survival in these patients.

Although isolated liver involvement in metastatic gastric cancer is rare, HAI seems to be similarly effective in these patients as in patients with liver metastases from colorectal cancer. The prognosis is significantly better in gastric cancer patients who have limited hepatic involvement and attain an objective response after HAI.