Adjuvant trastuzumab in routine clinical practice and the impact of cardiac monitoring guidelines on treatment delivery.

Trastuzumab delivery and changes in left ventricular ejection fraction (LVEF) in 110 patients receiving adjuvant trastuzumab in routine practice are investigated. The potential impact of new, less stringent UK cardiac monitoring guidelines is examined. 86 patients (78%) completed trastuzumab on schedule. 11 (10%) completed treatment despite delay(s) to allow LVEF recovery, 7 (6%) discontinued trastuzumab because of insufficient LVEF recovery, 2 (2%) of whom developed symptomatic cardiotoxicity. 6 (5%) discontinued trastuzumab for non-cardiac reasons. With the newer guidelines, the value of LVEF lower limit of normal is important in determining the proportion of patients who require angiotensin-converting enzyme inhibitors (ACEIs) and cardiology referral: up to 100% could potentially complete trastuzumab on schedule with up to 60% receiving ACEIs and 25% requiring cardiology referral. Adjuvant trastuzumab was well tolerated overall. The new guidelines potentially allow more patients to complete trastuzumab on schedule but require higher levels of cardiological intervention.

Metastatic struma ovarii: late presentation, unusual features and multiple radioactive iodine treatments.

Metastatic malignant struma ovarii is rare and there is a lack of agreement on the criteria of diagnosis and the lines of management. Here we describe a patient with struma ovarii that was initially diagnosed as benign and presented 10 years later with distant metastases. At this time, a pathological review of the initial lesion found that it contained invasive well-differentiated follicular carcinoma. The case was associated with a number of unusual features and challenging management issues, such as a delayed diagnosis of recurrence, functioning metastases with treatment consequences, tumour lysis-induced thyrotoxicosis and cerebrospinal fluid rhinorrhea. The diagnosis and management of struma ovarii should be led by an expert multidisciplinary team. Radioactive iodine should be considered in the management of metastatic disease.

Audit of compliance to adjuvant chemotherapy and radiotherapy guidelines in breast cancer in a cancer network.

The North Trent Cancer Network Breast Group in the United Kingdom revised its adjuvant treatment guidelines in breast cancer management in 1998. We aimed to check the compliance to the guidelines, 8 months after their introduction. Data were collected, retrospectively, from the medical records of patients with invasive breast cancer who underwent definitive surgery (in a 3-month period) in different cancer units and the cancer centre within the North Trent Cancer Network. The overall compliance to treatment guidelines was 82% (90% and 74% for chemotherapy and radiotherapy, respectively), which was similar across the network. In 5% of cases, compliance could not be determined. On case review, 22% of the non-compliant incidents were justified and 16% seemed to be due to variation in guideline interpretation. We discuss the possible reasons for non-compliance and show a need to periodically monitor compliance to adjuvant treatment guidelines.

Treatment of tumours of the parotid gland and middle ear using obliquely reconstructed computed tomographic images.

Conventional planning of radiotherapy of tumours of the parotid, middle ear and other tumours in the head and neck often requires the treatment plane to be non-transverse. This produces major problems in delineating the tumour as well as verifying that vital structures such as the spinal cord are not included in the target volume. The use of computed tomography (CT) generally overcomes some of these problems and we have developed an algorithm to reconstruct transverse CT images into the appropriate oblique plane. Software has been written on the Picker Independent Treatment Planning System (ITPS) to allow planning on central axis and off-axis oblique planes. In addition we have used a beam's eye view facility to aid in the verification process.

A double blind trial of nitroglycerin vasodilator ointment in patients undergoing cytotoxic chemotherapy.

A randomized double blind controlled trial has shown that topical, nitroglycerin vasodilator cream applied to the intended injection site in patients undergoing cytotoxic chemotherapy for various malignancies, produced detectable vasodilation and a decrease in minor aids to venepuncture compared to placebo. It did not decrease the number of attempts at cannulation needed nor the overall cannulation failure rate and cannot be recommended for general use in cytotoxic chemotherapy clinics.

Kupffer-cell depletion in chronic liver disease: implications for hepatic carcinogenesis.

It is suggested that the increased incidence of hepatocellular carcinoma complicating cirrhosis may be related to the lobular and nodular depletion of liver macrophages. The occurrence of other hepatic tumours can also be related to the anatomical distribution of these macrophages within the liver. These observations are consistent with the hypothesis that the liver macrophage (Kupffer cell) may play an important role in tumour surveillance.

Lysozyme in chronic liver disease: a biochemical and histological study.

Serum lysozyme activities and semiquantitative analysis of tissue lysozyme distribution were studied in patients with primary biliary cirrhosis (PBC), chronic hepatitis (CH), miscellaneous liver diseases, and normal subjects. Serum lysozyme was significantly raised in PBC and CH. Portal venous blood has similar lysozyme activities to peripheral venous blood in a group of various liver diseases. Lysozyme-containing intralobular cells were decreased in all liver diseases studied but portal tract lysozyme was increased only in PBC and CH. Thus the increase in serum lysozyme in PBC and CH appears to originate from the portal inflammatory infiltrate, seen in these diseases.