Experiencia en la utilización del fentanilo transdérmico en un servicio de Oncología radioterápica

Introduction

This observational study, conducted in an Oncology Radiotherapy Service, was performed to evaluate efficacy and toxicity of TTS-fentanyl, and patient satisfaction with the treatment.

Material and methods

Patients (n=225) with non-controlled pain, intolerance to oral opioids or with dysphagia were recruited. Evaluations were at baseline (commencement of TTS-fentanyl treatment) and after 72 hours, 30 days and 60 days of follow-up at which times pain intensity, TTS-fentanyl doses, secondary effects and patient satisfaction were assessed.

Results

Of the patients, 68% commenced TTS-fentanyl treatment following failure of weaker opioids. After 60 days, the mean decrease in pain intensity was 4.06 points on the visual analogue scale (p<0.05). Sideeffects were low or moderate. Satisfaction was evaluated as high by 58%, moderate by 32% and unsatisfactory by 10% of patients.

Conclusion

We conclude that TTS-fentanyl, because of its ease of preparation, efficacy and good toxicity profile, is a useful analgesic in an Oncology Radiotherapy Service.     

Grupo de Investigación Clínica en Oncología Radioterápica (GICOR): presentación y descripción estatutaria

El Grupo de Investigación Clínica en Oncología Radioterápica (GICOR) describe sus objetivos y organización interna. Se trata de una iniciativa con estructura de grupo cooperativo multiinstitucional desarrollado para promover investigación clínica y conocimiento con potencial influencia asistencial en la interacción de fármacos y radioterapia, en indicaciones preventivas o de soporte sintomático, o para modular el efecto antitumoral de la irradiación (radiopotenciadores, protectores, etc.). El convencimiento de que la investigación clínica estructurada en el contexto de un grupo cooperativo puede facilitar el desarrollo de ensayos clínicos metodológicamente superiores a las experiencias en instituciones Únicas ha impulsado esta iniciativa Las señas de identidad del GICOR son: investigación clínica aplicada en la interacción fármacosirradiación y voluntad de influir en la práctica asistencial mediante el conocimiento generado.     

Cirugía oncoplástica en tumores de pared torácica

Introduction

Surgical treatment of tumours of the chest wall (primary or metastatic) requires special skills by the thoracic and the plastic surgeons, from the functional as well as the aesthetic perspective (oncoplastic surgery), when the treatment requires surgical reconstruction.

Material and methods

We present a series of 14 patients who needed extensive resection of the thoracic wall (external and/or 3 or more ribs) with disease-free margins and reconstruction with prostheses (7 with polytetrafluoroethylene [PTFE^®] and 7 with the Sandwich Marlex—Methyl Metacrylate^®) technique with additional covering with muscle-skin flaps (6 pectoral, 5 recto-anterior, 3 dorsal) pedicled during the same surgical intervention.

Results

The aetiology of the extirpated tumours, following pathology assessment, were: 4 chondrosarcoma, 3 metastatic sternum, 2 breast cancer relapse, 1 desmoid tumour, 1 neurofibrosarcoma, 1 rhabdomiosarcoma, 1 malignant schwannoma and 1 radiation induced sarcoma. One patient died from complications and another 4 from disease progression before the conclusion of the study follow-up (3–22 months).

Conclusions

Extensive resection of tumours of the chest wall with reconstruction using prostheses and muscle-skin flaps is a safe method that can be performed in the same surgical intervention period when combining the skills of the thoracic surgeon with that of the plastic surgeon.     

La asociación entre metaplasia intestinal de la unión esofagogástrica y enfermedad for reflujo gastroesofágico en el Instituto Nacional de Cancerología

Introduction

Intestinal metaplasia in the oesophagus-gastric junction can originate in the distal oesophagus causing oesophagus-gastric reflux, or in the proximal portion of the stomach. This pre-malignant lesion can progress to cancer.

Objective

To determine the frequency of intestinal metaplasia of the oesophagus-gastric junction in patients with clinical gastric-oesophageal reflux and to evaluate the relationship with the chronic gastritis andHelicobacter pylori infection.

Material and Methods

Between March 2000 and June 2001, all patients who were referred to the Service of Endoscopy, without a diagnosis of cancer of the digestive tract and who, according to the Carlsson-Dent questionnaire, were classified as having oesophageal-gastric reflux were included in the study. Conventional endoscopy was performed and biopsies were obtained from the oesophagus-gastric junction. The pathologist who evaluated the samples was blinded with respect to the clinical details of the patients.

Results

The patients (n=51) included 20 men and 31 women, with a mean age of 53,7 years. The junction type was squamous-columnar in 30 patients and heterotopic “Z” type in 21. There were 17 patients with hiatus hernia and 12 with acute oesophagitis. Endoscopy indicated 6 patients with acute gastritis, 19 with chronic gastritis and 5 cases of Barrett's oesophagus. Histology indicated 3 patients with Barrett's oesophagus, 48 with chronic gastritis, 12 with cardial metaplasia and 34 withHelicobacter pylori infection.

Conclusions

Twelve (23.5%) patients presented intestinal metaplasia. In 66.6% there wasH. pylori infection and 48 patients (94.1%) had chronic gastritis. Endoscopically, the more frequent squamous-columnar junction was the heterotopic type in 58.8% with the type “Z” in 41.2% of patients.     

Quimioterapia de inducción seguida de radioquimioterapia como alternativa a la laringuectomía en el tratamiento del cáncer de cabeza y cuello localmente avanzado

Objective

To evaluate survival in patients with loco-regional advanced head and neck cancer treated with induction chemotherapy and to assess possible larynx preservation in good responders.

Materials and methods

Between December 1997 and June 2000, patients (n=46) diagnosed as having advanced head and neck carcinoma were treated with induction chemotherapy (CT). This was followed by radiotherapy (RT) + CT if there had been complete response (CR) or partial response (RP) >80%; or followed by total laryngectomy and adjuvant RT if CR or PR was <80%.

Results

Of the 46 patients studied, 57 (80%) had CR, 10% had PR and 10% had no response or disease progression (DP). Median survival was 33%, followup was of 50 months during which the overall survival was 36%, disease-free survival (DFS) was 60% and loco-regional control was 51%.

Conclusion

RT-CT resulted in high rates of disease resolution and speech preservation in patients who, traditionally, had poor clinical and functional outcomes.     

Cirugía de rescate en el cáncer colorrectal metastásico

El objetivo del estudio es el análisis de la supervivencia en el cáncer colorrectal metastásico tras la cirugía de rescate. Entre 1991 y 1998 se diagnosticaron 498 pacientes con cáncer colorrectal. En 10 pacientes se realizó cirugía de rescate de metástasis metacrónicas hepáticas o pulmonares. Se analizaron las características clínicas, el tratamiento realizado y la supervivencia. Siete fueron hombres y 3 mujeres con edades comprendidas entre 36–75 años (mediana: 61 años). La localización más frecuente fue recto seguida de sigma. Sólo 3 pacientes tenían afectación ganglionar. La localización más frecuente de las metástasis fue hepática, seguida de pulmonar. El nÚmero de metástasis fue 3 en un paciente, 2 en 3 pacientes y en el resto fue Única. El tamaño osciló entre 2 y 6,5 cm. La mediana del intervalo libre de enfermedad hasta el diagnóstico de la metástasis fue de 17 meses (rango: 8–48). El intervalo libre de enfermedad tras metastasectomía fue de 15,5 meses de mediana (rango: 3–72). La mediana del tiempo de seguimiento fue 47 meses (rango: 19–97). La cirugía de rescate de las metástasis hepáticas y pulmonares del cáncer colorrectal puede ofrecerun aumento de la supervivencia en pacientes seleccionados.     

Linfoma angiocéntrico centrofacial. Características clínicas, de tratamiento y seguimiento de 40 pacientes (experiencia en el Instituto Nacional de Cancerología, México)

Fourthy patients with diagnosis of angiocentric centrofacial lymphoma were seen in the Instituto Nacional of Cancerology, México, among 1982 to 1999. The following features were considered: age, sex, primary tumor site, main symptoms, treatment, outcome and histopathologic findings. There was a ratio male to female of 1.5:1 with mean age of 44 years (range, 18 to 98 years). The most frequent initial manifestation was in nasal cavity (50%), continued by palate (15%). The main symptoms included fever, nasal obstruction and rhinorrea. The treatment was grouped in four categories thus, eight patients received chemotherapy, thirteen patients chemotherapy followed by radiotherapy, 14 patients treated with radiotherapy followed by chemotherapy, and five patients received only radiotherapy. The patients whom besides development tuberculosis, and AIDS, had an aggressive course. The average of follow up in these 40 patients was 32 months. The patients treated with radiotherapy followed by chemotherapy showed better response and survival. The angiocentric centrofacial lymphoma, is an aggressive, quickly progressive disease, with T/NK cells type, associated with EBV and more aggressive in immunocompromised patients, mainly in patients with AIDS and tuberculosis. The treatment scheme with better results was that of patients receiving radiotherapy followed by chemotherapy.     

Variabilidad en la utilización del tratamiento conservador del cancer de marna localizado en un área geográfica

Objetivos

Conocer el porcentaje de tratamiento conservador del cancer de marna en estadios I y II en un área geográfica, la variabilidad de indicación entre diferentes centros y los posibles factores relacionados.

Métodos

En un estudio de corte transversal retrospectivo se recogieron un total de 225 casos de cáncer de marna en estadios iniciales y se determinó el tipo de cirugía (conservadora o mastectomía) y su relación con posibles predictores de la misma.

Resultados

La frecuencia de conservación mamaria fue del 27% para el conjunto de casos (IC del 95%, 22–34%). En el estadio I se realizó en el 49% de casos y en el estadio II en el 21%. La probabilidad de ser tratada con tratamiento conservador no pudo establecerse ni con la edad de la paciente ni con el área de residencia rural o urbana, pero si de forma significativa con el centro de tratamiento y el estadio.

Conclusiones

La menor frecuencia de conservación en estadio II no se ajusta en nuestro medio a los estándares aceptados. Factores propios de cada centro o del cirujano que atiende a la paciente pueden explicar la variabilidad en la frecuencia de indicación de conservación mamaria entre ellos.     

Aplicación del método de Gail de cálculo de riesgo de cáncer de mama a la población valenciana

Background

The objective of this study was to verify whether the method defined by Gail is applicable and predictive in a population of women in Valencia (Spain).

Population and methods

Of the 685 patients diagnosed with breast cancer and attended-to in 2000–2001, 186 incident cases were identified. The variables studied were obtained from a specific questionnaire which included characteristics of reproductive history, number of biopsies and contraceptive pill consumption prior to the diagnosis. Using the model of the National Surgical Adjuvant Breast and Bowel Project (NSABP), an adaptation of the Gail model, the risk of developing breast cancer at 5 years was estimated.

Results

Only 40% of those women diagnosed as having breast cancer would have been identified as a high-risk patient by the Gail method. With our population group, the method detected the elderly women with a medical history of breast cancer who developed advanced stage disease.

Conclusions

The Gail method does not adapt well to the study population of Valencia. It would be necessary to add other risk-factors to the Gail method so as to identify more patients in our area.     

Experiencia actual (1993–1999) del Grupo Cooperativo de Carcinoma Broncogénico de la Sociedad Española de Neumología y Cirugía Torácica (GCCB-S)

El Grupo Cooperativo de Carcinoma Broncogénico de la Sociedad Española de Neumología y Cirugía Torácica (GCCB-S) se constituyó en 1993 y durante 4 años ha registrado 2.992 casos de carcinoma broncogénico tratados quirÚrgicamente (CBQ) en 19 hospitales españoles. Con los datos del GCCB-S se ha podido validar la nueva clasificación TNM-estadios de 1997 para esta enfermedad. En nuestra experiencia, el estadio IIA es poco frecuente y a los 2 años de evolución tras la terapia no presenta diferencias pronósticas con los estadios colindantes. Un tumor T2N0M0c de gran tamaño se comporta pronósticamente a corto plazo como un estadio superior. En nuestra serie, la morbilidad quirÚrgica es del 32,4%; el nivel de mortalidad global del 6,6%; en el análisis multivariante, la presencia de neumonectomía o de enfermedad vascular periférica eran factores de riesgo independientes para la mortalidad operatoria. En resumen, la experiencia del GCCB-S con pacientes con CBQ está permitiendo conocer, entre otros aspectos, el pronóstico segÚn la estadificación vigente y los riegos quirÚrgicos en nuestro medio.     

Resultados del tratamiento a largo plazo de 209 niños con leucemia linfoblástica aguda: experiencia de un grupo multicéntrico en Venezuela

Introduction

We present the results of the treatment of 209 children suffering from acute lymphoblastic leukaemia (ALL) using th 87-01 treatment protocol from the Dana Farber Cancer Institute (DFCI), modified by the Instituto Venezolano de los Seguros Sociales Cooperative Group (IVSS-CG). Protocol 87-01 IVSS-CG is a prospective multi-centred trial for the treatment of children with newly-diagnosed ALL. Our goals were to compare event-free survival (EVS) in a group treated with doxorubicin (dox) at 30 mg/m² versus a group treated with epirubicin (epi) at 40 mg/m² and to evaluate the use of radiotherapy (XRT) of 18 Gy + met-hotrexate (mtx) intrathecal (IT) administered and IT cytarabine (IT-Ara-C). The original protocol recommended using 24 Gy + IT mtx.

Materials and methods

Between 1989 and 1998, 209 patients were treated. They were classified into three groups of standard risk (SR), high risk (HR) and very high risk (VHR) according to the DFCI ALL protocol. Induction treatment phase: all groups received asparaginase (asp), vincristine (vcr), prednisone (pred), epirubicin (epi) or doxorubicin (dox) and IT Ara-C. The SR patients received mtx 40 mg/m² and the HR and the VHR groups received high dose mtx of 4 g/m². The CNS prophy-laxis in SR was mtx IT and 18 Gy irradiation of the cranium, while the HR and VHR groups received mtx + Ara-c IT + 18 Gy. Intensification treatment phase: SR group received vcr; pred, 6-mercatopurine (6-MP) every 3 weeks plus mtx and asp weekly for 20 weeks. The HR and VHR groups received asp weekly up to the cumulative toxic doses of dox or epi. The VHR group received an initial phase of intensification with high dose mtx and Ara-C. The maintenance in all groups was with POMP until 24 months of continuous complete remission.

Results

There were 80 patients (38%) classified as SR, 102 (49%) as HR and 27 (13%) as VHR. With a median follow-up of 8 years, the 8-year disease-free survival (DFS) was 68% ± 4% (DFS ± SE) for all patients, 72% ± 4% of the 80 SR patients, 62% ± 4% for the 102 HR patients and 63% ± 11% for the 27 VHR patients. Comparison of DFS between groups (SR vs. HR vs. VHR) indicated a Chi² of 3.35 which was not statistically significant (p=0.18). The DFS was 62% for the 72 patients who received dox and which was similar to that of the 57 patients who received epi.

Conclusions

There were no statistically significant differences in results between the patients receiving dox and those receiving epi (p=0.79). Radiation at 18 Gy was as effective as 24 Gy in preventing CNS involvement.     

Utilidad diagnóstica de la tomografía de emisión de positrones en la evaluación de los gliomas

La tomografía de emisión de positrones (PET) proporciona imágenes de la distribución de algunos isótopos radiactivos de vida corta que representan procesos bioquímicosin vivo. Esta revisión considera las ventajas y limitaciones de la PET en la evaluación de los tumores cerebrales, en concreto de los gliomas. Las principales aplicaciones son:a) aproximación al grado tumoral de las neoplasias cerebrales;b) diferenciar la recurrencia de la radionecrosis;c) valoración de la extensión para el manejo terapéutico, yd) seleccionar el sitio óptimo para la biopsia. La F-18-fluorodesoxiglucosa (F-18-FDG) es el trazador más utilizado. En general, los tumores de alto grado presentan una captación elevada de F-18-FDG. De forma similar, una captación de F-18-FDG elevada se asocia con un tumor de alto grado y peor pronóstico, aunque existe un considerable solapamiento de hallazgos. Una dificultad inherente se refiere a la elevada captación de las sustancia gris normal. La PET-FDG presenta dificultades en la detección de los gliomas de bajo grado porque su captación puede ser relativamente baja en relación con el córtex normal. Por esta razón los tumores de bajo grado pueden pasar desapercibidos para la PET-FDG; sin embargo, la PET con C-11 metionina (C-11-MET) y otros trazadores y la imagen estructural correlativa generalmente ofrecen el diagnóstico correcto. La PET-MET permite delinear la extensión del tumor, sin tener en cuenta el grado de malignidad. La imagen metabólica con FDG puede ser Útil en la detección precoz de la recurrencia de los tumores cerebrales, diferenciándola de la radionecrosis tardía. Esto solamente es cierto si el tumor ya era visualizado con PET-FDG antes del tratamiento, así que la PET-MET podría proporcionar menos estudios falsos negativos. Se discuten también algunas causas no malignas de captación anormal y los efectos del tratamiento. En conclusión, la PET ha demostrado utilidad clínica en la evaluación de los tumores cerebrales de origen glial, ofreciendo información adicional a la imagen anatómica. F-18-FDG y C-11-MET pueden desempeñar papeles complementarios.     

Síndrome de supresión del antiandrógeno: estrategia terapéutica en el cáncer de próstata andrógeno-independiente

|Introduction

The anti-androgen withdrawal syndrome is a well-established phenomenon in prostate cancer. It is widely accepted that a subset of patients will benefit from the withdrawal of anti-androgen or steroid hormone from hormonal therapy; the result being a decrease in prostate-specific antigen (PSA) values and clinical improvement. In our study, we review our experience in patients with prostate cancer in progression stage (androgen-independent prostate cancer) and the effect of anti-androgen withdrawal (evaluation of response; duration of response) as well as assessing the possible predictive factors.

|Material and methods

We studied 70 patients with prostate cancer in biochemical progression receiving hormonal therapy. We evaluated the response three months after anti-androgen withdrawal. Considered as response was the reduction of PSA levels of >50%. The Chi-squared test and the Fisher exact test were the statistical analyses used to identify possible predictive factors.

|Results

We observed a PSA reduction of >50% in 22 patients (31.4%), a stabilisation of PSA levels in 9 of the patients, and biochemical progression in 39 patients (68,6%). The mean duration of response was 5 months. We observed a greater percentage of response to the withdrawal of bicalutamide than to flutamida, but the differences were not statistically significant. Only the duration of prior hormonal therapy appeared to predict the response to antiandrogen withdrawal. Currently, it is not possible to identify the subset of patients whose tumors will respond to anti-androgen or steroid withdrawal. Tumors that respond may be classified as androgen-independent and hormone-sensitive tumors as opposed to androgen-independent and hormone-insensitive tumors, which do not respond. Patients who respond to anti-androgen withdrawal experience an improved quality of life for approximately 6 months. However, it is not known whether this translates into prolonged survival.

|Conclusions

Since about 30% of patients will respond to anti-androgen or steroid withdrawal in hormone-refractory prostate cancer, this needs to be taken into account in clinical trials of new cytotoxic agents. Cessation of flutamide for at least 4 weeks and, perhaps even 8 weeks in the case of bicalutamide, is mandatory before anti-androgen withdrawal syndrome can be excluded as the cause of a decrease in PSA values.     

Paraparesia secundaria a metástasis intramedular como manifestación inicial de un carcinoma microcítico de pulmón

Intramedullary metastases (IM) are uncommon and rarely considered the initial presentation of malignancy. Lung and breast cancer account for most of the primary tumors. Magnetic resonance imaging may facilitate recognition of IM in patients with clinical features of myelopathy. A case of a unique intramedullary metastases as the presenting feature of an occult lung cancer is described.     

Radioterapia experimental. Parámetros de respuesta tumoral a la radiación

El conocimiento de los parámetros que definen la respuesta a la radiación de los tumores malignos, en particular el coeficiente de regeneración de los clonógenos tumorales supervivientes y la velocidad del proceso de proliferación tumoral subyacente, puede inferirse hoy día a partir de observaciones clínicas precisas, combinando los elementos básicos de la irradiación (dosis-tiempo-fraccionamiento) con los resultados del tratamiento (probabilidad de control observada) y ciertos supuestos relativos al efecto biológico radioinducido sobre los tumores tratados (relaciones dosis-supervivencia, dosis-tiempo y dosis-control tumoral). Ello explica la profunda transformación experimentada por la radioterapia durante los Últimos años. Del empirismo inicial se ha pasado a la aparición de un cuerpo doctrinal sólido, construido sobre bases racionales que permite formular hipótesis, predecir resultados, profundizar en el conocimiento de la biología de los tumores malignos y adoptar decisiones clínicas, impensables hace sólo una o dos décadas, en la terapéutica del cáncer. La radioterapia oncológica se ha configurado así como una disciplina con claros fundamentos científicos e importante proyección clínica, muy alejada de su carácter intuitivo inicial.     

Resultados a largo plazo de radioterapia y quimioterapia concomitante en cáncer microcítico de pulmón, enfermedad limitada al tórax, fuera de ensayos clínicos

Introduction

Chemotherapy combined with radiotherapy can improve local control and survival in patients with small cell lung cancer (SCLC).

Material and methods

We used cisplatin and etoposide (PE) with concurrent thoracic radiation therapy (TRT) followed by prophylactic cranial irradiation (PCI) in patients achieving a complete response. The objective was to evaluate the efficacy and toxicity of this regime in patients with localised SCLC. Patients (n=89) diagnosed with localised SCLC were treated with PE (4 to 6 cycles) together with TRT (50–60 Gy).

Results

The response rate was 92% (62%CR, 30%PR). The 20 patients with CR had PCI administered. Grade III–IV toxicities were 68% neutropenia, 23% thrombocytopenia, 23% anaemia and 24% severe dysphagia. Median overall survival rate was 17 months (probable survival rate of 35% at 2 years).

Conclusions

The treatment is feasible and provides acceptable survival rates despite the accompanying toxicity. It is recommended that PCI be provided for all patients achieving complete response.     

Supervivencia a largo plazo con quimioterapia a altas dosis de rescate en pacientes con cáncer de células germinales metastásico. Análisis de los patrones de recidiva

Objective

To evaluate survival and relapse patterns in 13 patients with recurrent, or refractory, germ-cell tumours treated with high-dose chemotherapy (HDC) and with peripheral blood stem-cell support.

Material and methods

All patients were treated in a single centre and received a median of 9 cycles (range 3–13) of cisplatinum-based chemotherapy (CT). The protocol consisted of: a) induction with ifosfamide-based CT (EPI: VP16 120 mg/m², ifosfamide 1.3 g/m², cisplatinum 25 mg/m²×4 days); b) mobilisation of PBSC with of either G-CSF (10 ug/kg/day) in 2 patients or EPI plus G-CSF, and c) HDC (carboplatin 350 mg/m², cyclophosphamide 1500 mg/m², VP16 400 mg/m²×3 days). G-CSF (5 μg/kg) was administered until haematopoietic graft. Median age=32 years (range 20–52); tumours=10/11 testicular (1 seminoma), 2 mediastinal. HDC was administered 21 months (range 6–66) post-diagnosis. Inclusion criteria: failure to achieve CR with conventional CT (n=5 patients), poor-prognosis mediastinal tumour (n=1), first recurrence after cisplatinum and ifosfamide-based CT (n=2) and second or third relapse (n=5). At the conclusion of HDC, 9/13 patients were in CR, 1 patient did not receive HDC because CNS progression but was included for survival analysis.

Results

Median times to graft were 9 and 13 days for leukocytes and platelets, respectively. Non-haematological toxicity was low and no therapy-related deaths occurred. Median disease free and overall survival were 19 and 30 months, respectively. Currently, 2 patients have not relapsed at 36 and 80 months. Previously-affected sites of disease were the unique sites of relapse in 5/11 (50%), concomitant distant relapse in 4/11 patients, CNS metastases in 1 patient. Rescue CT consisted of either oral VP16 or CBDCA/Taxol, which induced a new response in 6/10 patients.

Conclusions

HDC achieves 20% improved survival in patients refractory to conventional chemotherapy and non-resectable tumours. No benefit was observed in HDC treatment in patients having only partial response to conventional chemotherapy. Relapse following HDC occurred mainly at previously affected sites.