C. Cirrincione

A majority of patients with metastatic testicular cancer achieve a complete remission as a result of current treatment programs. However, patients who fail to achieve a complete remission have a very poor prognosis, and nearly all die of their disease. A multivariate logistic regression analysis of several clinical variables associated with prognosis was performed using data from 171 patients treated for metastatic testicular cancer at Memorial Hospital between September 1975 and February 1981. A mathematical model was identified which correctly predicted 94% of complete remissions and 83% of all outcomes. The variables achieving statistical significance were the logarithm of the serum values of lactate dehydrogenase (p less than 0.001) and human chorionic gonadotropin (p less than 0.001) and the total number of sites of metastasis (p less than 0.001). The model was tested against 49 patients with metastatic testicular cancer treated at the University of Minnesota Hospitals, and it correctly predicted 86% of complete remissions and 84% of all outcomes. In a highly curable disease such as testicular cancer, mathematical modeling may enable the clinical investigator to anticipate those patients who are least likely to do well. Alternate treatment strategies would be appropriate for such patients.

Primary central nervous system lymphoma (PCNSL), an uncommon tumor, is occurring with increasing frequency. Conventional therapy with corticosteroids and cranial radiotherapy (RT) usually gives a dramatic initial response, but median survival is only 10 to 18 months. Chemotherapy is more successful in comparable systemic lymphoma and has been employed for PCNSL at relapse, causing remission but not cure. Between June 1985 and June 1988, we prospectively staged 32 patients with PCNSL at Memorial Sloan-Kettering Cancer Center and treated 28 on a new protocol that combined chemotherapy and radiotherapy at diagnosis. None had occult systemic lymphoma, but 19% had ocular and 69% had definite or probable leptomeningeal lymphoma. There were no complications in 19 stereotactic biopsies, but 4/10 patients who had a complete resection suffered a severe postoperative deficit. Four patients received RT alone, and 28 received chemotherapy and cranial RT, 17 of whom (group A) received a combination regimen using pre-RT systemic (1 g/m2) and intra-Ommaya methotrexate (MTX), 4,000 cGy whole-brain RT with a 1,440 cGy boost, and 2 courses of post-RT high-dose cytosine arabinoside; 5 other patients received an identical regimen but with a decreased dose of MTX (200 mg/m2). Sixty-three percent of assessable patients had a response to MTX independent of corticosteroid and prior to RT. Eighteen of 26 (69%) assessable patients who received combined therapy are alive with a median follow-up of 25.4 months. Twelve of 16 (75%) assessable group A patients are alive in the same period. Chemotherapy-related toxicity was minimal, and no late toxicities have occurred to date.(ABSTRACT TRUNCATED AT 250 WORDS)

To identify risk factors in the development of arm edema (AE) after conservative management of breast cancer, the authors prospectively measured differences in upper and lower arm circumference in 282 patients with stage I or II breast cancer who received radiation. AE was defined as a difference of 2.5 cm or more in either measurement between treated and untreated arms. Median follow-up was 37 months (range, 7-109 months). The crude frequency of AE overall was 19.5% (55 patients). In 21 patients (7.4%) AE was transient; 34 patients (12.1%) had persistent AE, which is the focus of this article. The 5-year actuarial incidence of persistent AE was 16%. The crude risk of persistent severe AE was 3.9%. Various factors were examined for their ability to enable prediction of AE. Treatment-related factors did not significantly enable prediction of AE, whereas factors related to patient size, such as body mass index, were strongly associated with both the frequency and severity of AE.

The majority of patients receiving cisplatin at a dose of 120 mg/m2 experience delayed nausea and vomiting occurring between 24 and 120 hours after chemotherapy administration. Ninety-one patients who were receiving cisplatin (120 mg/m2) as initial chemotherapy were entered into this double-blind trial. All patients received intravenous (IV) metoclopramide, dexamethasone, and lorazepam for the control of acute emesis during the period from 0 to 24 hours after cisplatin. Patients were then randomized to one of three treatment regimens: placebo; oral dexamethasone, 8 mg twice daily for two days, then 4 mg twice daily for two days; or the combination of oral metoclopramide, 0.5 mg/kg four times daily for four days, plus oral dexamethasone administered as above. Forty-eight percent of individuals who received the two-drug combination of metoclopramide plus dexamethasone experienced delayed vomiting as opposed to 65% who were administered dexamethasone alone and 89% who received placebo (P = .006). Scores assessing the severity of delayed nausea and vomiting were consistently worse in individuals receiving placebo. The incidences of sleepiness, restlessness, heartburn, hiccoughs, loose bowel movements, insomnia, and acute dystonic reactions did not differ significantly among the three regimens and were mild and self-limited. The two-drug combination of oral metoclopramide plus dexamethasone is well tolerated, safe, and more effective than dexamethasone alone or placebo in controlling delayed vomiting following cisplatin.

We reviewed the records of patients treated for single brain metastases from non-small-cell lung cancer for 1978 through 1982. Forty-three patients received surgical treatment, including 37 who had surgery plus postoperative whole-brain radiation therapy and 6 patients who had surgery after failing to respond to radiation therapy. The surgically treated patients were matched with 43 patients treated with radiation therapy alone. The combined therapy group had significantly longer survivals than those treated with radiation therapy alone (19 months versus 9 months). The rates of local recurrence and neurologically related deaths were significantly higher in the radiation therapy-alone group. Patients treated with combined therapy survived longer, and the increased survival was due to lower recurrence of brain metastases after surgery and fewer neurologically related deaths.