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Background: Combination chemotherapy for metastatic breast cancer will palliate symptoms in the majority of patients but only a small percentage will have prolonged survival. Higher doses of doxorubicin lead to increased response rates in breast cancer and early studies have shown that epirubicin could be tolerated in higher doses with less relative toxicity than doxorubicin., Aims: This study was initiated to assess the dose of epirubicin that could be tolerated by escalating its dose while maintaining a fixed dose of cyclophosphamide. Simultaneously tumour response rate, spectrum of toxicities, duration of response and overall survival in patients with metastatic breast cancer were assessed., Methods: Patients with metastatic breast cancer commenced chemotherapy with a starting dose of epirubicin of 120 milligram per metre squared (mg/m2) and cyclophosphamide 600 mg/m2. The dose of epirubicin was to be escalated or reduced depending on toxicity., Results: Forty female patients were entered into this study and three patients withdrew because of toxicity. Overall tumour response rate was 75% with 27.5% of patients obtaining a complete response. Median time to progressive disease was 35 weeks and median overall survival was 48 weeks, with median survival for complete responders being 103 weeks. Thirty-one (77%) patients completed five or more courses of treatment. Haematological toxicity was the main side effect and 70% of patients required a dose reduction. No patients were eligible for a dose escalation. One patient died as a consequence of neutropenic sepsis. Four (10%) patients had treatment ceased because of decrease in left ventricular ejection fraction and one patient died as a consequence of heart failure. Four patients remain alive., Conclusions: High dose epirubicin combined with cyclophosphamide is an effective treatment regimen for metastatic breast cancer obtaining higher overall response rates with increased percentage complete responses compared to conventional dose chemotherapy. Although toxicity was increased, high dose chemotherapy was well tolerated and mortality associated with treatment was not increased. No dose escalations of epirubicin were possible and a dose of 90 mg/m2 of epirubicin would be the maximum dose when used in combination with cyclophosphamide. Further trials are required to determine the influence of this high dose therapy on survival duration and whether comparable benefits can be achieved with shorter durations of therapy.

Background: There are no Australasian data on the preferred information content of letters from consultant physicians to referring doctors., Aims: To survey referring general practitioners (GPs) and specialists concerning their preferences for letters from a consultant physician after a new patient consultation to include different categories of information. To investigate the information content of letters written by one medical oncologist to referring doctors after a new patient consultation and contrast with that of individualised letters written to patients., Methods: Fifty-five referring GPs and 53 specialists were sent a questionnaire seeking their views on the information content of letters from consultant physicians. Ninety-four letters after a new patient consultation were selected at random and analysed for their information content, and compared with 182 individualised letters sent to patients., Results: Referring doctors wanted letters to contain details of diagnosis, clinical findings, test results and recommended future tests, treatment options, side effects and prognosis. Letters to referring doctors contained 19 items of information (range 8-33), while letters to patients contained a mean of 5.6 'salient' points (range 5-7). Both letters almost always stated the diagnosis, the presenting history and recommended treatment. Letters to patients more commonly presented information about prognosis, further tests, and explanation of symptoms than letters to doctors. In contrast, letters to referring doctors contained more information concerning the past medical, family, and drug history, clinical findings and test results., Conclusions: Letters sent by a consultant oncologist are not well tailored to the information needs of the referring clinician. Summary letters sent to patients may be modified to include information required by referring doctors.

Three patients with Burkitt's lymphoma have been seen at Royal Prince Alfred Hospital during the past 18 months. Following treatment, two patients are in complete clinical remission.

We treated 105 patients with advanced breast cancer, using the progestational agent medroxyprogesterone acetate (MPA), 200 mg orally tds in a non-randomised trial. In general they were a poor risk population, since 78 had received prior endocrine therapy (21 more than one type) and 58 prior chemotherapy. Treatment was well tolerated. Side effects included weight gain, muscle cramps, fine tremor and fluid retention, but these were usually mild, resolved if the dose of drug was reduced, and only one patient stopped treatment because of toxicity. Seventeen patients died within six weeks of starting MPA, and disease progression occurred in a further 58. Nine have had stable disease for periods ranging from two to 11 months, and there were 21 who showed disease regression. Response to treatment continues in 13 of these patients, and at the time of writing the median duration of response is 10 months. Response rates were similar in pre- and post-menopausal patients. The dose of MPA was double to 400 mg tds in 16 patients whose disease had progressed on 200 mg tds, but no additional responses were seen in this group. Seven out of 24 (29%) patients who had not received prior endocrine therapy responded to high dose oral MPA, a response rate similar to that seen following other hormonal manipulations, but because the drug also has activity against hormone-resistant tumours and is well tolerated, it should have role in the treatment of advanced breast cancer.

Eight cases of primary cerebral lymphoma (PCL) are presented, being the largest Australian series of this rare condition reported to date. The clinical, radiological, anatomical and histological features were found to be comparable with those of patients reported in other series between 1954 to 1986. The precise treatment of PCL remains undetermined due to its rarity and apparent heterogeneity. Whole brain irradiation forms the basis of therapy although the role of prophylactic spinal irradiation, surgery and chemotherapy have not been defined. Response to corticosteroids and chemotherapy has been documented. Reported cases associated with the acquired immune deficiency syndrome (AIDS) are discussed. With an anticipated increase in the number of cases of AIDS, the incidence of related PCL will also increase. Large, multicentric trails are required to further delineate optimal treatment.

Initial blind liver biopsy established a histological diagnosis of metastatic cancer in 27 out of 34 patients who presented with clinical signs of liver metastases and no obvious primary tumour. Twenty-two of the patients had metastatic adenocarcinoma, and a primary tumour site was identified before death in only four patients.

Thirty-seven patients with advanced ovarian cancer were treated in a prospective, randomised trial comparing chlorambucil with a combination of cyclophosphamide and cis-diamminedichloroplatinum (cis DDP). Treatment with the combination was associated with an increased overall response rate (69% versus 23%) (p = 0.04). A response was associated with a longer median survival but no survival advantage was demonstrated for patients who received cyclophosphamide/cis DDP. A larger study is needed to evaluate fully the potential of regimens containing cis DDP in the management of advanced ovarian cancer.

Twenty-seven consecutive patients were treated with 3 mg oral lorazepam and 2.5 mg intravenous haloperidol in an effort to improve patient tolerance of cytotoxic chemotherapy and decrease nausea and vomiting. Antiemetic efficacy and side-effects were assessed using a patient questionnaire. Vomiting either did not occur, or was considered to be of only moderate intensity in 22 patients (81%) and usually ceased within 24 hours of commencing chemotherapy. Similarly, nausea was either absent or of only moderate severity, lasting less than 48 hours in the majority of patients. Eight of 11 patients who had received similar previous cytotoxic treatment with antiemetic agents but not lorazepam considered that lorazepam and haloperidol had considerably improved their tolerance of chemotherapy. The side-effects of haloperidol and lorazepam were mild and well tolerated.

Thirty-eight patients with advanced breast cancer, resistant to prior endocrine therapy and in most cases prior chemotherapy, were treated with aminoglutethimide, 250 mg qds. Seven of 30 evaluable patients (23%) responded. Six have subsequently relapsed with a mean duration of response of 17 weeks, while one continues to respond after 50 weeks of therapy. Six additional patients (20%) had stable disease during aminoglutethimide therapy (mean duration of 16 weeks). Three of the seven responders had shown a partial response, two had stable disease and two had progressive disease on prior endocrine therapy (including tamoxifen); six of the seven patients responding to aminoglutethimide had received prior combination chemotherapy, to which all had responded. Aminoglutethimide was generally well tolerated, although three patients withdrew from treatment within the first two weeks because of intolerable drowsiness. Aminoglutethimide offers a useful alternative to surgical adrenalectomy for women with advanced breast cancer responsive to previous endocrine and cytotoxic chemotherapy.

Fifty-three patients with Hepatocellular Carcinoma (HCC) from three Sydney teaching hospitals were examined for possible evidence of Hepatitis B virus (HBV) infection. Hepatitis Surface Antigen (HBsAg) was positive in 38% of those in whom it was sought, a higher incidence than previously reported in an Australian series. A further 13 patients had antibody to Hepatitis B core (Anti-HBc), but negative HBsAg, confirming past exposure to HBV. Where serum was available evidence of HBV infection was obtained in 62% of patients. It is argued that the incidence of HBV infection may be shown to be higher still with the advent of new technology as applied to HBV assays and tissue stains. The need to be aware of the growing evidence of a strong association between Hepatitis B virus and the development of HCC is stressed and the clinical implications are discussed.