Percutaneous drainage and combined praziquantel-albendazole therapy: a novel approach for the treatment of simple echinococcal liver cysts.

Cystic echinococcosis (CE) is a worldwide helminthic zoonosis causing serious disease in humans. The WHO Informal Working Group on Echinococcosis recommends a stage-specific treatment approach of hepatic CE that facilitates the decision on what therapy option is most appropriate. Percutaneous aspiration, instillation of a scolicide, e.g., ethanol or hypertonic saline, and subsequent re-aspiration (PAIR) have been advocated for treating medium-size unilocular WHO-stage CE1 cysts. PAIR can pose a risk of toxic cholangitis because of spillage of ethanol in the case of a cysto-biliary fistula or of life-threatening hypernatriaemia when hypertonic saline is used. The purpose of our study is to develop an alternative, safe, minimally invasive method to treat CE1 cysts, avoiding the use of toxic topic scolicides.We opt for percutaneous drainage (PD) in four patients: the intrahepatic drainage catheter is placed under CT-fluoroscopy, intracystic fluid is aspirated, and the viability of intracystic echinococcal protoscolices is assessed microscopically. Oral praziquantel (PZQ) is added to albendazole (ABZ) instead of using topical scolicidals.Protoscolices degenerate within 5 to 10 days after PZQ co-medication at a cumulative dosage of 250 to 335 mg/kg, and the cysts collapse. The cysts degenerate, and no sign of spillage nor relapse is observed in the follow-up time of up to 24 months post-intervention.In conclusion, PD combined with oral PZQ under ABZ coverage is preferable to PAIR in patients with unilocular echinococcal cysts.

Improving the Initial Breast Cancer Consultation.

BACKGROUND: Research shows providing cancer patients with adequate information has many benefits, but how do nurse practitioners know whether the initial consultation meets the information needs of their patients? Furthermore, how can the initial consultation be improved? OBJECTIVE: A low-cost continuous quality improvement process centered on decreasing distress and increasing information satisfaction was piloted to determine its effectiveness and feasibility. METHODS: Immediately before and after an initial consultation with a breast cancer surgeon, 59 women completed a questionnaire to measure distress and specific problems they were having. They then completed a questionnaire to measure information satisfaction. Pre-post changes in the distress score and number of problems were analyzed, as was information satisfaction. Feasibility was qualitatively examined. RESULTS: For the study sample, pre-post median distress scores decreased significantly (from 5 to 3, Chi-square = 5.73, p < .017). Information dissatisfaction scales were identified. The process was deemed feasible. CONCLUSIONS: This effective and feasible process may help the nurse practitioner continuously improve the initial consultation process. IMPLICATIONS FOR NURSING: (a) the initial breast cancer consultation is important, (b) a novel process for improving the initial breast cancer consultation is proposed, and (c) this feasible, low-cost process should be embedded into normal practice operations.

Lifetime cost-effectiveness analysis of intraoperative radiation therapy versus external beam radiation therapy for early stage breast cancer.

BACKGROUND: To date no one has examined the quality of life and direct costs of care in treating early stage breast cancer with adjunct intraoperative radiation therapy (IORT) versus external beam radiation therapy (EBRT) over the life of the patient. As well no one has examined the effects of radiation exposure with both therapies on the longer term sequelae. The purpose of this analysis was to examine the cost-effectiveness of IORT vs. EBRT over the life of the patient. METHODS: A Markov decision-analytic model evaluated these treatment strategies in terms of the direct costs in treating patients over their lifetime (including the downstream costs associated with radiation exposure) and the resultant quality of life of these patients. Medicare reimbursement amounts in treating patients were used for acute, steady state, recurrent cancer(s), and complications associated with radiation exposure. Quality adjusted life years (QALYs) derived from the medical literature were assessed with each of these states. Life expectancies as well were derived from the medical literature. Cost-effectiveness was evaluated for dominance and net monetary benefit [at a willingness to pay (WTP)] of $50,000/QALY. Sensitivity analysis was also performed. RESULTS: IORT was the dominant (least costly with greater QALYs) versus EBRT: total costs over the life of the patient = $53,179 (IORT) vs. $63,828 (EBRT) and total QALYs: 17.86 (IORT) vs. 17.06 (EBRT). At a willingness to pay of $50,000 for each additional QALY, the net monetary benefit demonstrated that IORT was the most cost effective option: $839,815 vs. $789,092. The model was most sensitive to the probabilities of recurrent cancer and death for both IORT and EBRT. CONCLUSION: IORT is the more valuable (lower cost with improved QALYs) strategy for use in patients presenting with early stage ER+ breast cancer. It should be used preferentially in these patients.

Twelve-month follow-up results of a trial utilizing Axxent electronic brachytherapy to deliver intraoperative radiation therapy for early-stage breast cancer.

BACKGROUND: Accelerated partial breast irradiation (APBI) is emerging as a valid alternative to whole-breast radiation therapy (WBRT) in breast-conserving therapy (BCT) for early-stage breast cancer. Axxent electronic brachytherapy (EBX) is a form of portable, balloon-based APBI that utilizes an electronic source of kilovoltage irradiation delivery with minimal shielding requirements. As such, EBX becomes a logical and convenient modality for delivery of intraoperative radiation therapy (IORT). We report 1-year results and clinical outcomes of a trial that utilizes EBX to deliver IORT for patients with early-stage breast cancer. METHODS: Eleven patients were enrolled on an institutional review board (IRB)-approved protocol. Inclusion criteria were patient age >45 years, unifocal tumors with infiltrating ductal or ductal carcinoma in situ (DCIS) histology, tumors ≤3 cm, and uninvolved lymph nodes. Preloaded radiation plans were used to deliver radiation prescription dose of 20 Gy to the balloon surface. RESULTS: The mean time for radiation delivery was 22 min; the total mean procedure time was 1 h 39 min. All margins of excision were negative on final pathology. At mean follow-up of 12 months, overall cosmesis was excellent in 10 of 11 patients. No infection, fat necrosis, desquamation, rib fracture or cancer recurrence has been observed. There was no evidence of fibrosis at last follow-up. CONCLUSION: IORT utilizing EBX is emerging as a feasible, well-tolerated alternative to postsurgical APBI. Further research and longer follow-up data on EBX and other IORT methods are needed to establish the clinical efficacy and safety of this treatment.

Intraoperative radiation therapy in the treatment of early-stage breast cancer utilizing xoft axxent electronic brachytherapy.

BACKGROUND: In an effort to overcome the barriers to BCT, alternative methods of delivering radiation therapy have been explored. APBI allows the radiation treatment to be accomplished in one week or less. XB is a form of balloon-based APBI that uses an electronic source generated by a mobile controller unit. Investigators have also explored IORT treatment that delivers a single fraction of radiation in the operating suite at the time of surgery. METHODS: We report on the first patient treated with XB to deliver IORT. RESULTS: IORT treatment utilizing XB is feasible and can be accomplished with a total procedure time of approximately 2 hours. CONCLUSION: Further research on XB and other methods of IORT is needed to establish clinical efficacy and safety for patients with early-stage breast cancer.

alphaB-crystallin is a novel predictor of resistance to neoadjuvant chemotherapy in breast cancer.

AIMS: alphaB-crystallin is an anti-apoptotic protein commonly expressed in poor prognosis basal-like breast tumors, which are largely triple (estrogen receptor (ER), progesterone receptor (PR), and HER2) negative. We examined whether alphaB-crystallin expression in breast cancer was associated with a poor response to neoadjuvant (preoperative) chemotherapy. METHODS: One hundred and twelve breast cancer patients who received neoadjuvant chemotherapy and who had post-chemotherapy tumor specimens available for analysis were included in the study. Forty-nine percent of patients were treated with doxorubicin and cyclophosphamide (AC), 37% received AC in combination with a taxane, and 14% received other regimens. Paired pre- and post-chemotherapy tumor specimens were available for 33 patients. alphaB-crystallin expression was determined by immunohistochemistry in tissue microarrays. RESULTS: Seventeen percent of tumors were alphaB-crystallin positive. alphaB-crystallin expression was identical in 32 of 33 cases for which both pre- and post-chemotherapy tumor tissue was available. alphaB-crystallin expression was associated with ER-negative (P = 0.0024) and triple negative status (P = 0.005). Overall response rates (ORR) defined as > or =50% reduction in tumor size after treatment were 53% (clinical ORR) and 61% (pathological ORR). Although tumor grade, size, ER, PR, HER2 or triple negative status was not associated with response, alphaB-crystallin-positive tumors had poorer overall response rates than alphaB-crystallin-negative tumors (clinical ORR, 21% vs. 59%, respectively, P = 0.0045; pathological ORR, 16% vs. 70%, respectively, P < 0.0001). CONCLUSION: alphaB-crystallin is a novel biomarker expressed predominantly in triple negative breast tumors that identifies a subset of chemotherapy-resistant tumors, which may contribute to their poor prognosis.

"It's much easier than going to the dentist": high levels of satisfaction in a mammography screening program.

OBJECTIVES: To develop a suitable instrument for measuring client satisfaction in the BreastScreen New South Wales (NSW) program and to use the instrument to measure client satisfaction. METHOD: The survey was designed and administered to 2,091 women who attended mammography screening in the BreastScreen NSW program during 2001 (85% response rate). The survey evaluated experiences of making appointments, the screening environment, the screening procedure, and the receipt of results. Socio-demographic differentials in client satisfaction were examined using logistic regression models. RESULTS: The majority of women were highly satisfied with their experience, with transport/parking, breast discomfort and time to results causing the most dissatisfaction (8-9%). The main source of dissatisfaction was during the appointment and related to discomfort during the mammogram (9%) and breast problems following the mammogram (9%). Predictors of dissatisfaction with screening (p<0.05) included high education level (OR=1.4), non-Australian born (OR=1.4), and aged 40-49 years (OR=1.6). CONCLUSIONS: Although overall satisfaction was high, the survey indicated service functions where improvements could be made. IMPLICATIONS: This research has developed an appropriate tool for assessing and monitoring client satisfaction with breast screening services.

Long-term review of a breast conservation series and patterns of care over 18 years.

BACKGROUND: Multiple randomized trials of breast conservation compared with mastectomy in early breast cancer have validated equivalence of survival. Overwhelmingly the standard management of breast conservation includes surgical removal of the tumour, axillary dissection, postoperative breast irradiation, and adjuvant systemic therapy as appropriate. The outcomes are reviewed of 832 women with early breast cancer treated by local resection and irradiation at Royal Prince Alfred Hospital over an 18 year period, with particular emphasis on the changing patterns of practice. METHODS: Between September 1978 and May 1996, 832 women with early stage breast cancer were treated with conservative surgery and radiation therapy. The changes in patient, tumour and treatment factors were analysed over this time period. The outcomes of local recurrence and survival were recorded. Trends in patterns of these variables were evaluated by dividing the 18 years accrual period into three consecutive periods (1978-1983, n = 28; 1984-1990, n = 392; 1991-1996, n = 412). RESULTS: At a median follow up of 76 months, the 5 and 10 year actuarial local recurrence rates were 4% and 6%, respectively. Half of the local recurrences were at the primary site. Young age, extensive intraduct carcinoma, oestrogen receptor (ER) status and extranodal spread were predictive of local recurrence on multivariate analysis. The 5 and 10 year overall survival rates were 88% and 73%, respectively. Actuarial 5 year local recurrence (4%, 6%, 2%) and survival (96%, 88%, 92%) rates varied little across the three time intervals. There was an increase in median age from 46 to 56 years over the accrual period, with no change in median primary tumour size (1.5 cm). There were significant histopathological improvements in reporting margin status and ER status. Surgically, the median number of axillary lymph nodes retrieved (14) did not alter significantly. With respect to adjuvant therapies, irradiation of lymph nodes regions decreased over time. The proportion of patients receiving adjuvant hormones or chemotherapy increased significantly (18%, 35%, 54%). CONCLUSIONS: The low local recurrence rate and high survival are consistent with published literature for early breast cancer. Changes in practice during the accrual period included improvements in histopathological reporting, a reduction in irradiation of lymph node regions, and an increase in the use of systemic therapy. These changes parallel international recommendations regarding the optimal management of early breast cancer.

Predictors of non-attendance from BreastScreen NSW in women who report current mammography screening.

OBJECTIVE: To identify among self-reported current screeners: (1) predictors of never attendance at BreastScreen NSW (BSNSW); (2) predictors of late or lapsed attendance to BSNSW (attendance to alternative providers). METHODS: Random samples of women aged 50-69 years were selected from the BSNSW database and NSW electoral roll as: current attenders to BSNSW (<27 months since last screen); late or lapsed attenders to BSNSW (>27 months since last screen); or women who had never attended BSNSW. The response rate was 71% (3,104) for a telephone interview that asked questions concerning demographics, medical status and health service usage, and opinions and behaviours related to mammography. RESULTS: Never attendance at BSNSW was predicted by higher income, advice from a doctor or nurse to have their last mammogram, recent clinical breast examination and belief that a referral letter is necessary. Late or lapsed attendance to BSNSW (and attendance to alternate providers) was associated with higher education, health insurance coverage, recent clinical breast examination and a family history of breast cancer. CONCLUSIONS: Currently screened women who do not attend BSNSW, or who are late or lapsed for a mammogram, appear to be influenced by referral patterns of their health care providers and their higher socio-economic status. IMPLICATIONS: BSNSW should be promoted to eligible women and general practitioners as a specialty mammography screening service that does not require a referral.