Susan Hilton

Treatment of patients with transitional-cell carcinoma of the urothelial tract with ifosfamide, paclitaxel, and cisplatin: a phase II trial.

PURPOSE A phase II trial of ifosfamide, paclitaxel, and cisplatin (ITP) was conducted in previously untreated patients with advanced transitional-cell carcinoma (TCC) to assess its efficacy and toxicity. PATIENTS AND METHODS Thirty patients with metastatic or unresectable TCC were treated with ifosfamide 1.5 g/m2/d for 3 days with paclitaxel 200 mg/m2 over 3 hours and cisplatin 70 mg/m2 on day 1 of each 28-day treatment cycle. Therapy was continued for a maximum of six cycles. Prophylactic hematopoietic growth factor (recombinant human granulocyte colony-stimulating factor [rhG-CSF]) was given on days 6 to 17 of each cycle. RESULTS Twenty-three of 29 assessable patients (79%; 95% confidence interval [CI], 60% to 92%) demonstrated a major response (six complete [CR] and 17 partial [PR]) with response durations that ranged from 5 to 24+ months. Five patients with T4 bladder primary tumors had a major response, two with pathologic CR. At a median follow-up duration of 17.9 months, nine (31%) patients remain disease-free (range, 10+ to 24+). Hematologic toxicity included anemia, thrombocytopenia, and neutropenia; febrile neutropenia was observed in 17% of patients and 4% of cycles. No grade 4 nonhematologic toxicity was observed. Grade 3 nonhematologic toxicity included alopecia, allergy (3%), renal insufficiency (13%), and neuropathy (10%). Dose reductions or drug omissions were necessary for adverse events in seven (23%) patients. CONCLUSION ITP is an active, well-tolerated regimen in previously untreated patients with TCC of the urothelial tract. Further study of this regimen in patients with both TCC and non-transitional-cell urothelial tumors is ongoing.

Phase I evaluation of sequential doxorubicin + gemcitabine then ifosfamide + paclitaxel + cisplatin for patients with unresectable or metastatic transitional-cell carcinoma of the urothelial tract

PURPOSE This phase I trial sought to evaluate the toxicity of and determine the maximum-tolerated dose (MTD) for the two-drug regimen doxorubicin and gemcitabine (AG) followed by the three-drug regimen of ifosfamide, paclitaxel, and cisplatin (ITP) in patients with unresectable or metastatic transitional-cell carcinoma. PATIENTS AND METHODS Patients received AG every other week for six cycles followed by ITP every 3 weeks for four cycles. Five AG dose levels were investigated, up to doxorubicin 50 mg/m(2) and gemcitabine 2, 000 mg/m(2), to determine the MTD of the regimen. The dose and schedule of ITP were constant: ifosfamide 1,500 mg/m(2) (days 1 to 3); paclitaxel 200 mg/m(2) (day 1); and cisplatin 70 mg/m(2) (day 1). Granulocyte colony-stimulating factor was given between all cycles of therapy. RESULTS Fifteen patients enrolled onto this phase I trial. AG was well tolerated at all dose levels, with no grade 3 or 4 myelosuppression. Toxicity experienced with ITP included grade 3 and 4 granulocytopenia in four patients and grade 3 nausea/vomiting in three patients. No grade 3 and 4 neurotoxicity was observed. Eight of 14 assessable patients experienced a major response to AG, including five of six patients treated at the two highest AG dose levels. After completion of AG-ITP, nine of 14 assessable patients had a major response (three complete responses and six partial responses). CONCLUSION AG is a well-tolerated and active regimen. Sequential chemotherapy with AG-ITP is also well tolerated, and phase II investigation at the highest dose level is ongoing.

Routine ct scan in cystectomy patients: does it chance management?

OBJECTIVES To evaluate the practical use of routine computed tomography (CT) scan in changing management of patients with muscle-invasive bladder cancer who are candidates for cystectomy. METHODS One hundred five patients (52 with tumors confined to the bladder and 53 with extravesical spread) were evaluated for cystectomy. The presence of nodal metastasis at surgery or biopsy was correlated with preoperative CT findings. RESULTS The CT scan was abnormal (nodes > 1.5 cm in size) in 32% and normal (nodes < 1.5 cm) in 68% of 28 patients with positive nodes. Of 52 cases with T2 tumors, CT scan was abnormal in 6, 14% (1 of 7) with positive and 11% (5 of 45) with negative nodes, whereas of 53 with T3-4 tumors, 15 had abnormal scans, 38% (8 of 21) with positive and 22% (7 of 32) with negative nodes. CT scan changed management (a biopsy deferred surgery) in 2 (2%) of the 105 cases. CONCLUSIONS A routine CT scan was not helpful in management of operable T2 tumors but might change therapy in selected patients with T3-4 tumors who are considered for cystectomy.

Radiographic versus pathologic size of renal tumors: Implications for partial nephrectomy

OBJECTIVES To compare the radiographic size with the pathologic size of renal tumors to determine whether these two measurements vary significantly and to evaluate whether any differences in tumor size could have an impact on the decisions regarding partial nephrectomy. METHODS In 87 renal tumors excised by partial nephrectomy, the maximum transaxial tumor size on computed tomography (CT) was compared with its corresponding pathologic transverse size. Tumors were locally excised after vascular occlusion and hypothermia. The average size of the tumors selected for partial nephrectomy by preoperative CT scan was 3.4 cm (range 1.9 to 9.3). The difference between the CT size and pathologic size was correlated with the histologic type of the renal tumors. RESULTS Of the 87 tumors, 52 (60%) were classified as clear cell carcinoma and 35 (40%) as other histologic types (papillary, chromophobe, oncocytoma, and angiomyolipoma). Clear cell carcinomas decreased an average of 0.97 cm versus 0.39 cm for the other tumor types. Of 62 tumors greater than 3 cm on CT, 43 averaged 0.87 cm smaller at pathologic evaluation (36 clear cell and 7 other types) and 19 showed no significant (less than 0.5 cm) decrease in size (2 clear cell and 17 other histologic types). Of 30 tumors greater than 4 cm on CT, 22 clear cell carcinomas shrank more than 1 cm and 8 tumors displaying other histologic features showed no decrease in size. CONCLUSIONS For renal tumors measuring greater than 4 cm, a decrease in tumor size may help facilitate partial nephrectomy, especially for clear cell carcinomas that do not extensively involve major vascular structures or the collecting system.

Whole-Body FDG-PET in Patients with Recurrent Colorectal Carcinoma: A Comparative Study with CT

Purpose: To assess the clinical accuracy of whole-body 2-[F-18]-fluoro-2-deoxy-D-glucose-positron emission tomography (FDG-PET) in the diagnosis of recurrent colorectal carcinoma in comparison to conventional computed tomography (CT).Materials and methods: Forty patients with suspected recurrent colorectal carcinoma based on either progressive serial carcinoemrbyonic antigen (CEA) serum elevation or positive/equivocal CT findings underwent whole-body FDG-PET. PET results were compared with those of CT and correlated to the final histopathological and clinical findings.Results: A final diagnosis was obtained at 93 sites in 35 patients by histology and in 5 patients by clinical follow up of at least 6 months. Of the 93 sites, 53 were determined to be malignant and 40 benign. FDG-PET evaluated on a 5-point scale (0-4) showed a positive and negative predictive value in the range of 96-98% and 83-93% respectively as the threshold for positivity was moved from 0 through 3. By comparison, CT, also evaluated on a 5-point scale showed a positive and negative predictive value in the range of 75-88% and 67-71% respectively. The area under the fitted receiver operating characteristic curve for PET: A(PET) = 0.96 +/- 0.02 was significantly greater (P < 0.001) than that observed for CT: A(CT) = 0.77 +/- 0.06. The distribution of maximum standardized uptake value (SUVmax) showed that all negative lesions have SUVmax below 5.0 whereas 75% of positive lesions were above 5.0 pointing to the fact that disease positivity is more likely in lesions with high SUV values.Conclusion: The results of this study confirm that whole-body FDG-PET is more accurate than conventional CT in the staging of patients with suspected recurrent colorectal carcinoma.

Clinical comparison of radiolocalization of two monoclonal antibodies (mAbs) against the TAG-72 antigen

Ten patients with colorectal cancer metastases received 125I-B72.3 and 131I-CC49 prior to laparotomy (five patients received 1 mg, and five 20 mg of each mAb). Tumor:serum ratios of 131I-CC49 were better than those of 125I-B72.3 (P < 0.01 at 1 mg; P = 0.05 at 20 mg; P < 0.01 at both doses). All known lesions > or = 1 cm in diameter were visualized at the 20 mg dose. There was no difference in absolute tumor uptake of 125I-B72.3 or 131I-CC49. We conclude that mAb CC49 has better relative uptake in colorectal cancers than mAb B72.3.

Routine editing of trainee-generated radiology reports: effect on style quality.

RATIONALE AND OBJECTIVES The authors performed this study to determine the effect of routine editing on the style quality of trainee-generated radiology reports. MATERIALS AND METHODS Trainee-generated reports of 50 body computed tomographic scans obtained at a tertiary care cancer center were edited in a routine fashion by one of two attending radiologists. Three physicians and four radiologists each independently evaluated the randomized unedited and edited reports (n = 100) and rated each report for clarity, brevity, readability, and quality of the impression by using a five-point scale. RESULTS Editing significantly improved mean ratings for clarity (4.6 after editing vs 4.2 before editing, P < .007), brevity (4.6 vs 4.2, P < .007), readability (4.4 vs 4.1, P < .007), and quality of the impression (4.5 vs 4.3, P < .007). CONCLUSION Routine editing of trainee-generated reports significantly improves the perceived report quality. This finding suggests that greater emphasis should be placed on stylistic aspects of reporting during training to improve report style quality at dictation.

Renal mass within a horseshoe kidney: preoperative evaluation with three-dimensional helical computed tomography

Tumors arising within a horseshoe kidney are uncommon and may be difficult to characterize. We report a case of transitional cell carcinoma in a horseshoe kidney. Although several conventional imaging techniques were used to define the mass, each provided limited information. Recent advances in computer technology permit radiologic imaging to provide detailed examination of the horseshoe kidney with a single study. We describe the use of three-dimensional multislice helical computed tomography as the preferred modality to clarify the suspected neoplasm, vasculature, and collecting system of a horseshoe kidney. High-quality anatomic characterization will certainly enhance the opportunity for nephron-sparing surgery within this population.

Preselection of Patients with High TAG-72 Antigen Expression Leads to Targeting of 94% of Known Metastatic Tumor Sites with Monoclonal Antibody I-131-CC49

We studied 18 consecutive patients with advanced colorectal cancer where primary tumors were preselected for high expression of TAG-72 antigen and who underwent a phase I radioimmunotherapy trial with an intravenously administered monoclonal antibody CC49, 20 mg, labeled with I-131 in amounts varying from 15 mCi/m2 to 75 mCi/m2. Whole-body images and SPECT of the abdomen obtained 1 week after infusion were compared with pretreatment CT scans. A total of 66 lesions were evaluated. SPECT revealed 2/66 lesions (3%) that were not detected by CT; 4/66 were only detected by CT: lungs (1.8 cm and < 1 cm), axilla (1.5 cm), adrenal (2.5 cm). Thus, based on immunohistopathological testing in paraffin-embedded tissue blocks of primary tumors stained for TAG-72 antigen, we have selected a subset of patients (about 70% of referrals) with colorectal cancer for whom I-131-CC49 was shown to target to 62/64 CT positive lesions (97%) and 62/66 (94%) of all known positive lesions. We conclude that in patients with significant TAG-72 tumor expression there is excellent targeting of I-131-CC49 in therapeutic doses to colorectal cancer with respect to lesions detected with CT scanning. It should be noted that this study was not designed as a comparison of the sensitivity of CT versus I-131-CC49 SPECT/planar imaging. Instead, the observed results are consistent with a biological hypothesis that in general, the primary tumor histology vis-à-vis TAG-72 expression reflects the TAG-72 expression of the metastatic sites.

Assessment of neurovascular involvement by malignant musculoskeletal tumors.

Determining the presence or absence of neurovascular involvement by a malignant musculoskeletal neoplasm is an important aspect of local tumor staging. This article discusses issues concerning such assessments made by diagnostic imaging techniques, including factors inherent to the patient and those related to imaging technology. The distinction between tumor contact and tumor encasement is emphasized and illustrated.