Radiation treatment for ductal carcinoma in situ (DCIS): is a boost to the tumor bed necessary?

The aim of the presented study was to evaluate the long-term outcome of breast-conserving surgery and radiation for the treatment of ductal carcinoma in situ (DCIS) and the role of the radiation boost to the tumor bed. The files of 75 women with DCIS treated by breast-conserving surgery followed by definitive radiation from 1988 to 1997 were reviewed for demographic data, prognostic variables, radiation dose, radiation boost, recurrence, and outcome. Total radiation dose was 5000 cGy delivered in 25 fractions. Twenty patients (26.7%) received an additional boost to the tumor bed of 1000 cGy in 5 fractions. Median follow-up time was 81.5 months (range, 22-145). Pearson correlation coefficient and its significance was calculated between the variables. Log rank test was used to analyze differences in local recurrence rates between patients who did or did not receive a boost, and a Cox regression model was fitted to the data to predict recurrence. Ten patients (13%) had local recurrence; one patient showed lymphatic spread. Histopathologic examination revealed DCIS in 6 cases (60%) and invasive duct carcinoma in 4 (40%)(one minimally invasive). The recurrence group included 3 of the 20 patients who received a radiation boost (15%) and 7 of the 55 who did not (12.7%) (p=0.7). Correlation analysis of patient characteristics, prognostic factors, and treatment was significant only between mastitis as the presenting symptom (n=4) and longer time to recurrence (p=0.02). The recurrence rate in the present study was similar to other series of conservative treatment for DCIS of the breast. No additional value was found for the radiation boost. Larger controlled randomized studies are needed to confirm these findings.

Pregnancy and radiation.

The risk of foetal irradiation during pregnancy is discussed. It seems that, due to the low level of X-ray exposure to the foetus, neither diagnostic radiography nor nuclear diagnostic examination justifies termination of pregnancy. Radiotherapy for breast cancer, Hodgkin's disease and cervical cancer in pregnant women is reviewed. Radiation therapy for breast cancer is not an absolute contraindication for pregnancy and the risk-benefit assessment should be discussed with the mother. The risk to the foetus during radiotherapy for supradiaphragmatic Hodgkin's disease appears to be minimal, provided special attention is paid to the treatment techniques and the foetus is adequately shielded. Radiotherapy for the treatment of cervical cancer may be necessary during pregnancy, but the timing should be adjusted taking into consideration gestational age. Offspring of cancer patients who were treated by radiotherapy appear to be at little risk of childhood cancer or birth defects. Cancer patients should not be discouraged from having children and can expect a good outcome of pregnancy. However, in the non-pregnant woman, to further reduce any risk it is advisable to delay pregnancy for 12 months following completion of radiation therapy.

Comparison of 5-FU and leucovorin to gemcitabine in the treatment of pancreatic cancer.

Gemcitabine has been recently added to the 5-fluorouracil (5-FU) protocol in the treatment of both new and 5-FU refractory patients with pancreatic cancer. We compared the efficacy of gemcitabine versus 5-FU and leucovorin (LCV) in 82 patients with advanced pancreatic cancer. Forty-seven patients received 5-FU and LCV and 35 patients received gemcitabine. Objective responses were documented in 4% on the 5-FU and LCV arm, compared to 9% in the gemcitabine arm. No change was observed in 48% on the 5-FU and LCV arm compared to 20% in the gemcitabine arm. Clinical benefit was observed in 19% on the 5-FU and LCV arm compared to 48% in the gemcitabine arm (p<0. 001). Toxicity was mild and well tolerated in both arms. One-year survival was 32% on the 5-FU and LCV arm and 23% in the gemcitabine arm. These results indicate that gemcitabine had a significantly higher clinical benefit than 5-FU and should be the standard treatment in advanced pancreatic cancer.

Soluble C-erbb-2 (p185) in breast-cancer patients in relation to prognosis.

Serum levels of P185-HER-2 were measured in 137 breast cancer patients and in 40 controls. The patients were divided into 4 groups: group A - 40 newly diagnosed patients; group B - 57 patients on long-term follow-up without active disease; group C - 26 patients with metastatic disease and group D - 5 patients with locally advanced inoperable tumors. The median level in controls was 4.8 U/l. The median P185 serum levels in groups C and D were significantly higher compared to groups A and B. In group C 60% and in group D 100% of patients had baseline elevated levels of serum P185 (>5 U/l) compared to 28% in groups A and B. Of the 14 patients in group A with elevated baseline levels of serum P185, 6 (43%) developed metastasis during the 24-month follow-up period. On serial measurements during follow-up in 23 patients of group A, 3 relapsed and the P185 level increased. In group C, serial measurements in patients with elevated baseline levels of P185 correlated with clinical response to therapy. These data suggest that serum levels of P185 are elevated in patients with metastatic disease. High initial P185 serum levels in new patients may have prognostic significance. Serial measurements of P185 in asymptomatic patients may help in monitoring disease state. In metastatic patients, serial P185 determination may be of benefit in assessing response to therapy.

Nucleolar organizer regions in conjunctival nevi and melanomata.

The objective of this study was to compare the argyrophil nucleolar organizer region (Ag-NOR) counts of conjunctival nevi and melanomata and to compare the efficacy of this method in their differential diagnosis. Nine histologically diagnosed conjunctival nevi and three conjunctival malignant melanomas were studied. Representative sections were stained using the AgNOR technique. Fifty cells of each melanocytic lesion were randomly selected without knowing their histologic diagnosis. The AgNORs were visualized at a magnification of x1000. They consisted of clusters >1 micron in diameter and of satellites <1 micron in diameter, which were counted and recorded for each cell separately. The mean AgNOR count for the nevi was 1.12 clusters and 1.72 satellites per cell, while the count for the melanomas was 1.6 clusters and 6.8 satellites per cell. These results are statistically significant. There was no overlap between the number of AgNOR clusters and satellites in conjunctival nevi and melanomas, indicating that the AgNOR count might be a useful tool in distinguishing benign from malignant conjunctival melanocytic lesions.

Initial TPS serum level as an indicator of relapse and survival in colorectal cancer.

BACKGROUND: Tissue polypeptide specific antigen (TPS) measures a soluble fragment of cytokeratine 18 and may be regarded as a proliferative marker. MATERIALS AND METHODS: TPS was measured in 173 consecutive patients with colorectal cancer. Median follow up time was 36 months. Of 137 evaluable patients 39 developed metastases (P.D.) and 98 remained with no evidence of disease (N.E.D.). RESULTS: Initial TPS levels were elevated in 75% of P.D. patients compared to 32% of N.E.D. patients (p < 0.001), CEA levels were elevated in 26% of P.D. patients had elevated initial TPS compared to 35.5% of N.E.D. patients (p < 0.001), CEA was elevated in 33.3% of the P.D. patients compared to 1.3% of N.E.D. patients (p < 0.001). Survival and disease free survival were significantly shorter for patients with initial high TPS level. TPS was more sensitive than CEA in predicting relapse. CONCLUSIONS: These preliminary data suggest that TPS may be a prognostic factor for relapse and may help to allocate Dukes'B2 patients for adjuvant chemotherapy.

A comparison of two dose regimens in pancreatic cancer.

Forty-seven patients with pancreatic cancer were treated with two different schedules of 5-fluorouracil (5FU) and leucovorin (LCV): standard and dose-intense schedules. The standard regimen was monthly and the dose intense was biweekly. Partial response was observed in one patient (4%), no change in 12 (48%) and progression of disease in another 12 patients. Clinical benefit, measured by symptomatic improvement, was observed in 19% of all the patients, in 12% of those treated with the standard regimen and in 27% of the intense group. Median survival was 8 months for all the patients. The 1-year survival rate was 32%. Toxicity was mild. There was no survival benefit for the dose intense regimen. These results indicate that clinical benefit can be obtained with 5FU and LCV regimens despite the lack of objective response and that a dose-intense schedule is of little benefit in treating pancreatic cancer.

The significance of soluble interleukin-2, soluble interleukin-2 receptors, soluble ICAM-1 and beta 2-microglobulin in breast cancer patients.

The serum levels of soluble interleukin-2 (sIL-2), sIL-2 receptors (sIL-2R), beta 2-microglobulin (beta 2M) and soluble intercellular adhesion molecule-1 (sICAM-1) were measured by the ELISA technique in 129 breast cancer patients and 40 controls. The median serum levels of sIL2-R, beta 2M and sICAM-1 were significantly higher and sIL-2 significantly lower than controls. sIL-2R, sICAM-1 and beta 2M levels were significantly higher in patients with metastatic disease compared to patients on long-term follow-up with no active disease. Initial study measurements of these markers could not identify patients at high risk for relapse. These findings suggest that the sIL-2R level is indicative of metastatic disease and together with other parameters of immune activation may be of help in monitoring disease activity in breast cancer patients.