Alan T. Lefor

Octreotide in the treatment of lymphorrhea after axillary node dissection: a prospective randomized controlled trial

BACKGROUND Axillary lymph node dissection for staging and local control of nodal disease is an integral part of breast cancer therapy. Lymphorrea is a serious and disabling complication of axillary lymphadenectomy, but no effective therapy is currently available. Octreotide is a hormone with general antisecretory effects that has been used to control lymphorrhea in thoracic duct injury and after radical neck dissection. The aim of the study we describe in this article was to determine whether octreotide has a role in the treatment of post axillary lymphadenectomy lymphorrhea. STUDY DESIGN This is a prospective randomized controlled trial. Two hundred sixty-one consecutive patients with various stages of breast cancer who underwent axillary lymph node dissection were randomized and followed for 7 years. The treatment group received 0.1 mg octreotide subcutaneously three times a day for 5 days, starting on the first postoperative day, while the control group received no treatment. Of the 261 patients undergoing axillary node dissection, 136 were assigned to the control group and 125 composed the treatment group. The control group and the treatment group were evaluated for amount and duration of lymphorrhea as well as inflammatory and infectious complications. RESULTS In the control group, the mean quantity (+/- standard deviation) of lymphorrhea was 94.6 +/- 19 cc per day and the average duration was 16.7 +/- 3.0 days. In comparison, the mean quantity of lymphorrhea in the treatment group was 65.4 +/- 21.1 cc (p < 0.0001) per day and the average duration was 7.1 +/- 2.9 days (p < 0.0001). We did not find an important difference in the number of infectious complication or hematomas formation between the study groups. CONCLUSIONS Octreotide can be used successfully for the treatment of post-axillary dissection lymphorrea, and potentially, in the prevention of post-axillary lymph node dissection lymphosarcoma, since the amount and duration of lymphorrhea in this setting are known to be important risk factors for its development. Potentially, octreotide might be used in similar situations where lymphorrhea is detrimental, such as peripheral vascular surgery and regional lymph node dissection for melanoma.

Androgen blockade enhances response to melanoma vaccine.

BACKGROUND Because preclinical studies suggest an interaction between androgens and the immune system, we used a murine model to determine whether androgen blockade with flutamide might enhance the immunogenicity of an irradiated melanoma cell vaccine. MATERIALS AND METHODS Forty C57BL/6 male mice were randomly assigned to four treatment groups: flutamide + RPMI (Group A), flutamide + irradiated B16 murine melanoma cells (Group B), placebo + RPMI (Group C), and placebo + irradiated B16 cells (Group D). Splenocyte proliferation and secretion of interleukin-2 and interferon-gamma were assayed after coculturing splenocytes with irradiated B16 cells. Antibody-dependent cellular cytotoxicity (ADCC) against B16 cells was determined using peripheral blood lymphocytes. To examine the effect of treatment on tumor growth, a second set of 40 mice assigned to Groups A, B, C, and D underwent tumor challenge 7 days after the last treatment. RESULTS Splenocyte proliferation was significantly higher in the two groups receiving flutamide at 50 mg/kg x 7 days (29% in Groups A and B vs 3% in Group C and 7% in Group D). Secretion of interferon was significantly higher in mice receiving flutamide + irradiated B16 cells (15.2 pg/ml in Group B vs 0, 1.7, and 4 pg/ml in Groups A, C, and D, respectively; P = 0.0024). Differences in interleukin secretion were not significant. ADCC was 26% in Group B vs 15, 8, and 22% in Groups A, C, and D, respectively (P = 0.0001). In the tumor challenge experiment, the rate of survival was 10% higher in mice receiving irradiated B16 + flutamide than in mice receiving irradiated B16 alone. CONCLUSION Flutamide can enhance immune responses to an irradiated whole-cell melanoma vaccine. A clinical study of immunotherapeutic androgen blockade is warranted.

Route of nutrition support

P rospective studies, meta-analyses, and current assessments of the literature have validated nutrition as a hallmark and a required staple in the care of select hospitalized patients. Aggressively administered nutrition support should be the standard of care when indicated, and prolonged periods of inadequate nutrition support leading to malnutrition should be avoided.1 However, an area of controversy exists surrounding the route of delivery and outcomes.2–8 Before 1968 the gastrointestinal (GI) tract was the only route available for nutrition support. Dudrick et al. revolutionized the management of patients dying from the inability to take enteral nutrition with the description of total parenteral nutrition (TPN).9 Once another route for nutrition support became available, the logical question that followed was, which one was better? Many articles in the literature have advocated enteral nutrition as the preferred route.2–4 These investigators argued that enteral nutrition maintains the integrity of the GI tract and has fewer infectious complications compared with TPN. However, there are as many articles that have found no difference between enteral nutrition and TPN.5–8