Liver resection for colorectal liver metastases in older patients

INTRODUCTION

Seventy-six percentages of patients with a newly diagnosed colorectal carcinoma are between 65 and 85 years old. A substantial proportion will develop liver metastases, for which resection is the only potential curative treatment. This study was conducted to investigate both the feasibility, and short- and long-term outcomes of liver resection for colorectal liver metastases in elderly patients.

METHODS

Between August 1990 and April 2007 data were prospectively collected on patients over 70 years of age who underwent a liver resection for colorectal liver metastases in a single centre.

RESULTS

One hundred and eighty-one liver resections were performed in 178 consecutive patients (median age 74 years). Thirty-four patients (18.8%) received neoadjuvant chemotherapy (all FOLFOX) prior to liver surgery and the majority (57.5%) of liver resections involved more than two Couinaud's segments. Median hospital stay was 13 days, 70 (38.5%) patients had postoperative complications, and overall in hospital mortality was 4.9% (9 patients). Overall- and disease-free survival rates at 1, 3 and 5 years were 86.1%, 43.2% and 31.5% and 65.8%, 26% and 16%, respectively. In multivariate analysis: T3 primary staging; major liver resections; more than three liver lesions; and the occurrence of postoperative complications were associated with inferior overall survival.

CONCLUSIONS

Liver resection for colorectal liver metastases in elderly patients is safe and may offer long-time survival to a substantial percentage of patients. We strongly recommend considering senior patients for surgical treatment whenever possible.

Docosahexaenoic acid dietary supplementation enhances the effects of exercise on synaptic plasticity and cognition

Omega-3 fatty acids (i.e. docosahexaenoic acid; DHA), similar to exercise, improve cognitive function, promote neuroplasticity, and protect against neurological lesion. In this study, we investigated a possible synergistic action between DHA dietary supplementation and voluntary exercise on modulating synaptic plasticity and cognition. Rats received DHA dietary supplementation (1.25% DHA) with or without voluntary exercise for 12 days. We found that the DHA-enriched diet significantly increased spatial learning ability, and these effects were enhanced by exercise. The DHA-enriched diet increased levels of pro-brain-derived neurotrophic factor (BDNF) and mature BDNF, whereas the additional application of exercise boosted the levels of both. Furthermore, the levels of the activated forms of CREB and synapsin I were incremented by the DHA-enriched diet with greater elevation by the concurrent application of exercise. While the DHA diet reduced hippocampal oxidized protein levels, a combination of a DHA diet and exercise resulted in a greater reduction rate. The levels of activated forms of hippocampal Akt and CaMKII were increased by the DHA-enriched diet, and with even greater elevation by a combination of diet and exercise. Akt and CaMKII signaling are crucial step by which BDNF exerts its action on synaptic plasticity and learning and memory. These results indicate that the DHA diet enhanced the effects of exercise on cognition and BDNF-related synaptic plasticity, a capacity that may be used to promote mental health and reduce risk of neurological disorders.

The Oncosurge strategy for the management of colorectal liver metastases – An external validation study

INTRODUCTION

Because most patients with colorectal liver metastases (CRLM) present to general surgeons and oncologists without a specialist interest in their management, a computer program (OncoSurge) has been created that identifies individual patient resectability and recommends optimal treatment strategies. The aim of this study was to validate the Oncosurge strategy by comparing its recommendations with the decisions made by a multidisciplinary (MDT) meeting, in a supra-regional hepatobiliary referral centre, using real cases with known outcomes.

METHODS

We reviewed the records and imaging of 98 consecutive patients with CRLM, who had been referred for decision making to our MDT meeting between January 1, 2004 and December 31, 2004. All patient and tumour characteristics were entered onto the Oncosurge decision model, which was accessed at www.evidis.com/oncosurge/

RESULTS

There was concordance between Oncosurge and MDT decisions in 93/98 cases. The observed kappa (kappa) was 0.850 (95% CI: 0.728-0.972). In descriptive terms, a kappa score greater than 0.8 equates to "almost perfect agreement".

CONCLUSIONS

Our results demonstrate the validity of the Oncosurge system when compared to one year of decision making in an established hepatobiliary MDT meeting. This confirms the utility of the Oncosurge system for decision making, audit and educational purposes.

Extensive necrosis of visceral melanoma metastases after immunotherapy

BACKGROUND

The prognosis for metastatic melanoma remains poor even with traditional decarbazine or interferon therapy. 5-year survival is markedly higher amongst patients undergoing metastatectomy. Unfortunately not all are suitable for metastatectomy. Alternative agents for systemic therapy have, to date, offered no greater rates of survival beyond traditional therapy. A toll-like receptor 9 agonist, PF-3512676 (formerly known as CPG 7909) is currently being evaluated for its potential.

CASE PRESENTATION

We present the case of a 54-year-old Caucasian male with completely resected metastatic cutaneous melanoma after immunotherapy. The patient initially progressed during adjuvant high-dose interferon, with metastases to the liver, spleen, and pelvic lymph nodes. During an 18-month treatment period with PF-3512676 (formerly known as CPG 7909), a synthetic cytosine-phosphorothioate-guanine rich oligodeoxynucleotide, slow radiologic disease progression was demonstrated at the original disease sites. Subsequent excision of splenic and pelvic nodal metastases was performed, followed by resection of the liver metastases. Histologic examination of both hepatic and splenic melanoma metastases showed extensive necrosis. Subsequent disease-free status was demonstrated by serial positron emission tomography (PET).

CONCLUSION

Existing evidence from phase I/II trials suggests systemic treatment with PF-3512676 is capable of provoking a strong tumor-specific immune response and may account for the prolonged tumor control in this instance.

Poly(3-hydroxybutyrate-co-3-hydroxyvalerate) composite biomaterials for bone tissue regeneration: in vitro performance assessed by osteoblast proliferation, osteoclast adhesion and resorption, and macrophage proinflammatory response

The efficacy of composite materials for bone tissue engineering is dependent on the materials' ability to support bone regeneration whilst inducing a minimal inflammatory response. In this study we examined the in vitro osteogenic and inflammatory properties of poly(3-hydroxybutyrate-co-3-valerate) (PHBV) with various calcium phosphate-reinforcing phases: nano-sized hydroxyapatite (HA); submicron-sized calcined hydroxyapatite (cHA); and submicron-sized beta-tricalcium phosphate (beta-TCP), using bioassays of cultured osteoblasts, osteoclasts, and macrophages. Our study showed that the addition of a nano-sized reinforcing phase to PHBV, whilst improving osteogenic properties, also reduces the proinflammatory response. Proinflammatory responses of RAW264.7/ELAM-eGFP macrophages to PHBV were shown to be markedly reduced by the introduction of a reinforcing phase, with HA/PHBV composites having the lowest inflammatory response. Osteoclasts, whilst able to attach to all the materials, failed to form functional actin rings or resorption pits on any of the materials under investigation. Cultures of osteoblasts (MC3T3-E1) readily attached and mineralised on all the materials, with HA/PHBV inducing the highest levels of mineralization. The improved biological performance of HA/PHBV composites when compared with cHA/PHBV and beta-TCP/PHBV composites is most likely a result of the nano-sized reinforcing phase of HA/PHBV and the greater surface presentation of mineral in these composites. Our results provide a new strategy for improving the suitability of PHBV-based materials for bone tissue regeneration.

The QuickDASH is an appropriate tool for measuring the quality of recovery after upper limb burn injury

BACKGROUND

Upper limb (UL) burns commonly result in significant dysfunction. The measurement of disability is vital to assess recovery after burn injury. The QuickDASH questionnaire was developed to evaluate UL disorders. The aim of this study was to evaluate its validity, repeatability and responsiveness for burn patients.

METHODS

In 2006, 85 patients with UL burns were recruited at Royal Perth Hospital. Each completed both QuickDASH and Burns Specific Health Scale-Brief (BSHS-B) at regular intervals after their burn. Further, 67 patients repeated the questionnaire 1 day after completing it at discharge.

RESULTS

Validity-Criterion validity was demonstrated between QuickDASH and BSHS-B through good correlations (r(2)=-0.79 to -0.89). Construct validity was demonstrated using burn severity markers. QuickDASH scores significantly differed when grouped according to major burn, full thickness burn, surgery and need for hospital admission. Repeatability-QuickDASH showed excellent repeatability (ICC=0.93). Responsiveness-Effect size of QuickDASH was demonstrated to be greater than BSHS-B at all measurement points.

CONCLUSIONS

This longitudinal study confirms the validity, repeatability and responsiveness of the QuickDASH outcome measure in patients with upper limb burns. It supports the use of the QuickDASH in this population to help assess change in functional level.

Dietary Lutein/Zeaxanthin Partially Reduces Photoaging and Photocarcinogenesis in Chronically UVB-Irradiated Skh-1 Hairless Mice

Lutein and zeaxanthin are xanthophyll carotenoids with potent antioxidant properties protecting the skin from acute photodamage. This study extended the investigation to chronic photodamage and photocarcinogenesis. Mice received either a lutein/zeaxanthin-supplemented diet or a standard nonsupplemented diet. Dorsal skin of female Skh-1 hairless mice was exposed to UVB radiation with a cumulative dose of 16,000 mJ/cm(2) for photoaging and 30,200 mJ/cm(2) for photocarcinogenesis. Clinical evaluations were performed weekly, and the animals were sacrificed 24 h after the last UVB exposure. For photoaging experiments, skin fold thickness, suprapapillary plate thickness, mast cell counts and dermal desmosine content were evaluated. For photocarcinogenesis, samples of tumors larger than 2 mm were analyzed for histological characterization, hyperproliferation index, tumor multiplicity, total tumor volume and tumor-free survival time. Results of the photoaging experiment revealed that skin fold thickness and number of infiltrating mast cells following UVB irradiation were significantly less in lutein/zeaxanthin-treated mice when compared to irradiated animals fed the standard diet. The results of the photocarcinogenesis experiment were increased tumor-free survival time, reduced tumor multiplicity and total tumor volume in lutein/zeaxanthin-treated mice in comparison with control irradiated animals fed the standard diet. These data demonstrate that dietary lutein/zeaxanthin supplementation protects the skin against UVB-induced photoaging and photocarcinogenesis.

Nuclear insulin receptor substrate-1 activates promoters of cell cycle progression genes

The insulin receptor substrate-1 (IRS-1) is a docking protein of the insulin-like growth factor-1 (IGF-1) receptor and of the insulin receptor. IRS-1 sends a strong mitogenic, anti-apoptotic signal and plays an important role in cell transformation and cancer. IRS-1 translocates to nuclei of cells, where it increases the activity of the rDNA, c-myc and cyclin D1 promoters. We show, by chromatin immunoprecipitation, occupancy by IRS-1 of the same promoters. Both promoter activation and promoter occupancy are IGF-1-dependent. In cells that respond to IGF-1 but in which IRS-1 does not translocate to nuclei, promoter occupancy is absent and promoter activation is absent or much reduced. Transcriptional activation of c-myc and cyclin D1 promoters by nuclear IRS-1 does not occur with a mutant, inactive IRS-1 protein (deletion of the phosphotyrosine-binding domain, PTB) and does not require PI3-kinase activity. Taken together, these results indicate a novel mechanism by which nuclear IRS-1 activates cell cycle genes.

A randomised controlled trial of the electric heating pad vs forced-air warming for preventing hypothermia during laparotomy

A randomised controlled trial was conducted to compare the efficacy of upper body forced-air warming (Bair Hugger, Augustine Medical model 500/OR, Prairie, MN) with that of an electric heating pad (Operatherm 202, KanMed, Bromma, Sweden) for maintenance of intra-operative body temperature in 60 patients undergoing laparotomy under general anaesthesia. The nasopharyngeal temperature was recorded throughout the operative period. The mean (SD) final temperatures were 36.2 (0.4) degrees C with forced-air warming and 35.5 (1.0) degrees C with electric heating pad (p < 0.01). Upper body forced-air warming is more effective than the heating pad for maintenance of body temperature during laparotomy.

Neoadjuvant docetaxel and capecitabine in patients (Pts) with high-risk prostate cancer (PCa): Final results of a phase II trial

5147

Background: Docetaxel is the most active cytotoxic agent in PCa. Pre-clinically docetaxel increases the expression of thymidine phosphorylase (TP), an enzyme responsible for activation of capecitabine to 5-fluorouracil. We assessed the activity and safety of neoadjuvant docetaxel and capecitabine (DC) in pts with high risk PCa. Methods: Non-metastatic PCa pts with clinical stage >T2, or PSA = 15 ng/ml or biopsy Gleason sum (GS) = 8 received 3–6 cycles of docetaxel (36 mg/m2 IV on days 1, 8, and 15) and capecitabine (1,250 mg/m2/day PO on days 5–18) q 28 days, followed by local therapy. The primary endpoint of this 2-stage phase II trial was rate of = 50% decline in PSA. Secondary endpoints included safety and correlative measures of treatment effect (qualitative changes in histology, tissue TP and survivin expression, and CK18Asp396 [apoptosis marker] in serum). Results: Fifteen pts were enrolled with median age of 58 years, median GS =8 and PSA of 23.2 ng/mL. Five pts met 1, 7 met 2, and 3 met 3 entry criteria. 14 pts completed 3 or more cycles of DC, with a median follow up of 17.5 months (9–34). Six of the 15 patients (40%) experienced a = 50% decline in PSA, which was below the 7 required for expansion of the study. Median testosterone did not change post therapy. Eleven pts underwent radical prostatectomy (RP), with no increase in surgical complications. Six pts had positive margins, and 2 had lymph node involvement. Of the 8 patients who underwent RP alone, 5 developed a biochemical recurrence in a median time of 11 months. Grade 3 or 4 toxicities were diarrhea(3), mucositis(2), hand foot syndrome(1) and neutropenia(2). Post versus pre therapy tissue had only mild chemotherapy-effects (4/7 samples), including focal clear cell changes, apoptosis/pyknosis, and necrosis. While there was no discernable pattern of increased TP expression, 4/7 specimens showed decreased survivin expression, suggesting a possible mechanism for chemotherapy-induced apoptosis. There was no correlation of PSA response and survivin expression and no increase in serum CK18Asp396. Conclusions: Docetaxel and capecitabine in the neoadjuvant setting is well tolerated, but results in modest pathologic and PSA responses. Supported by Sanofi- Aventis.

No significant financial relationships to disclose.

Analysis of organ motion effects on the effective fluences for liver IMRT

An effective fluence concept was employed to make forward dose calculations to investigate the effects of a distorted fluence map on dose plans. Fluence changes caused by organ motion were calculated using Chui's algorithm (2003 Med. Phys. 30 1736). In two test cases with various fluence maps, the effects of motion were simulated using a maximal displacement from 5 mm to 25 mm; 108 fluence maps that were calculated from 16 IMRT plans for eight liver cancer patients were analyzed and compared with and without gating. Fluoroscopic measurements were made of a moving diaphragm in this study. Fluence changes associated with superior-inferior organ motion, perpendicular to the moving MLC, were also examined. The effects of motion on the fluence maps were evaluated from both the fluence differences between static and motion and the chi function. The maximum displacements of the organs in all of these cases were analyzed and correlated with the change in fluence generated from the liver IMRT plans. The dosimetric effects on the target coverage were evaluated for each plan. The results indicate that, for the same fluence map, the mean fluence intensity error or the percentage of the fluence points that have an unacceptable error is linearly related to the extent of motion. For different fluence maps, the degree to which the fluence is distorted by motion is strongly related to the product of the motion extent and the fluence gradient in the direction of diaphragm motion. For eight liver patients and 16 IMRT plans in this work (with gated technique, motion extent from 0.5 cm to 1.0 cm; without gated technique, motion extent from 0.9 cm to 1.8 cm), the fluence modulations are mild, such that the respiratory motion of each patient did not strongly affect the CTV coverage. The mean dose error is 1.5% for free motion (0.9-1.8 cm) and is around 1% for gated motion (0.5-1 cm).

Breast skin doses from brachytherapy using MammoSite HDR, intensity modulated radiation therapy, and tangential fields techniques

Skin doses from brachytherapy using MammoSite HDR, Intensity Modulated Radiation Therapy (IMRT), and conventional tangential fields techniques were compared. For each treatment technique, skin doses were measured using paired thermoluminescent dosimeters placed on the patient's skin: (i) directly above the balloon catheter during MammoSite HDR brachytherapy treatments and (ii) 4 cm inside the treatment borders during the IMRT and conventional breast treatments. The mean dose measured was about 58% of the prescription dose for the patients treated using the MammoSite technique. On the other hand, for patients treated with IMRT and tangential fields, the mean dose was found to be about 69% and 71% of the corresponding prescription dose. This study suggests that in breast cancer radiation treatments the MammoSite HDR technique reduces skin doses compared to IMRT and tangential field techniques.

Transposon-based interferon gamma gene transfer overcomes limitations of episomal plasmid for immunogene therapy of glioblastoma

Despite improvements in gene delivery technology, transient expression of plasmid DNA has limited the efficacy of nonviral vectors applied to cancer gene therapy. We previously developed plasmid DNA vectors capable of transgene integration and long-term expression in human glioblastoma cells by utilizing the Sleeping Beauty (SB) transposable element. In this study, we compared the efficacy of interferon gamma (IFN-gamma) immunogene therapy using episomal or SB vectors in a syngeneic GL261 glioma model. Gene delivery was achieved by intratumoral convection-enhanced delivery of DNA/polyethylenimine complexes. Only mice treated with SB transposase-encoding DNA to facilitate chromosomal integration exhibited a significant increase in survival (P<0.05). SB-mediated intratumoral gene transfer caused sustained IFN-gamma expression assessed by reverse transcription-polymerase chain reaction, of both vector-derived and endogenous IFN-gamma, whereas expression following episomal plasmid gene transfer was undetectable within 2 weeks. Median survival was enhanced further when SB-mediated IFN-gamma gene transfer was combined with CpG oligodeoxynucleotides as adjuvant therapy. Prolonged survival positively correlated with tumor regression measured by in vivo bioluminescent imaging, and enhanced T-cell activation revealed by the ELISPOT assay. SB appears to improve the efficacy of cytokine gene therapy using nonviral vectors by enhancing the duration of transgene expression.

Four-dimensional computed tomography-based respiratory-gated whole-abdominal intensity-modulated radiation therapy for ovarian cancer: a feasibility study

This study assesses the feasibility and implementation of respiratory-gated whole-abdominal intensity-modulated radiation therapy (RG-WAIMRT). Three patients were treated with RG-WAIMRT. The planning target volume (PTV1) included the entire peritoneal cavity and a pelvic boost field was created (PTV2). The dose prescribed was 30 Gy to PTV1 and 14.4 Gy to PTV2. For comparison, a conventional three-dimensional (3D) plan was generated for each patient. In the WAIMRT plan, an average of 90% of PTV1 received 30 Gy compared to 70% for the conventional 3D plan. The percent volume receiving 30 Gy (V30) for liver averaged 54% (WAIMRT) vs 43% (3D). The percent volume receiving 20 Gy (V20) for kidneys averaged 19% vs 0%, and the mean V20 for bone marrow was 74% vs 83%, respectively. Major acute toxicities were anemia (grade 2: 1/3), leukopenia (grade 3: 2/3 patients), and thrombocytopenia (grade 2: 1/3 patients, grade 3: 1/3 patients). One patient could not complete the whole-abdomen field after 19.5 Gy because of persistent nausea. No major subacute toxicity has been reported. WAIMRT demonstrated superior target coverage and reduced dose to bone marrow, with a slightly increased dose to liver and kidneys. WAIMRT is a novel and feasible technique for ovarian cancer treatment.

Abdominal organ motion measured using 4D CT

PURPOSE

To measure respiration-induced abdominal organ motion using four-dimensional computed tomography (4D CT) scanning and to examine the organ paths.

METHODS AND MATERIALS

During 4D CT scanning, consecutive CT images are acquired of the patient at each couch position. Simultaneously, the patient's respiratory pattern is recorded using an external marker block taped to the patient's abdomen. This pattern is used to retrospectively organize the CT images into multiple three-dimensional images, each representing one breathing phase. These images are analyzed to measure organ motion between each phase. The displacement from end expiration is compared to a displacement limit that represents acceptable dosimetric results (5 mm).

RESULTS

The organs measured in 13 patients were the liver, spleen, and left and right kidneys. Their average superior to inferior absolute displacements were 1.3 cm for the liver, 1.3 cm for the spleen, 1.1 cm for the left kidney, and 1.3 cm for the right kidney. Although the organ paths varied among patients, 5 mm of superior to inferior displacement from end expiration resulted in less than 5 mm of displacement in the other directions for 41 of 43 organs measured.

CONCLUSIONS

Four-dimensional CT scanning can accurately measure abdominal organ motion throughout respiration. This information may result in greater organ sparing and planning target volume coverage.

A timing and process flow analysis of opening clinical trials within an oncology cooperative group setting: The case of the CALGB

6015

Background: Cooperative oncology groups are major sponsors of Phase III clinical trials, yet the number of steps and times required to setup and open such a trial have yet to be studied. This study assesses these items in the Cancer and Leukemia Group B (CALGB) for all Phase III studies opened in a 3 year period. Methods: Step 1: headquarters and statistical center staff were interviewed to discover the detailed steps required for a study to transit from initial concept submission by a potential study chair to final activation of the study. The formal procedures manuals were also reviewed. All study records and draft protocol documents were inspected to verify and identify additional setup steps. Finally, data was collected through direct contact with study chairs and disease committee chairs. Step 2: timing data for each of the major functions or processes were collected. All times are from initial initiation of the function to the final completion of the task. Times represent calendar time. Step 3: creation of stream-lined process flows, currently underway. Members from the CALGB and the Vanderbilt Center for Management Research in Healthcare (cmrhc.org) will spend 2 days creating a process to significantly reduce the time and the number of steps to opening a trial. Results: A total of 13 Phase III studies were activated during the 3 years study period. 372 processes are required to open a Phase III at CALGB, which include 314 work steps, 43 major decision points. Interesting, most of the decision points (63%) are external to CALGB. There are 23 processing loops that require repeating processes. The process map, which lists all processes, is a chart 243.5” × 41 in 8 pt font (or about the length of a 20 passenger bus). Median calendar days to activate a Phase III study at CALGB is 767 days (min = 488, max = 1,441). The three functions requiring the greatest median days are protocol development (477), forms development (434), and regulatory affairs (350). Conclusion: It can require years to open a Phase III study at a major cooperative oncology group. Using process redesign techniques, we expect to be able to significantly streamline the process. Support provided by the NCI.

No significant financial relationships to disclose.

Localizing moving targets and organs using motion-managed CTs

Respiration-induced target and organ motion impacts the radiotherapy strategies of some cancers. Various methods and techniques have been used to investigate motion-related radiotherapy issues, including retrospective 4-dimensional (4D) computed tomography (CT), prospective gated CT, and breath-hold CT scans. This paper reviews these methods and, particularly, the method using retrospective 4D CT scans, which has been developed at our institution. Some motion studies based on retrospective 4D CT images of patients are also examined. These studies have led to reduced planning target volume (PTV) margins for a number of patients, because the respiratory motion was observed to be minimal or gated radiotherapy was used. Respiratory motion managed CTs and, particularly, retrospective 4D CTs are proving to be useful for measuring soft tissue motion, identifying patients who could benefit from gated radiotherapy, and evaluating the effects of respiratory motion during radiotherapy.

Patient Set-up in Radiotherapy with Video-based Positioning System

The precision of patient position set-up is important in radiotherapy. A simple and effective scheme is proposed to calibrate the binocular cameras into the treatment machine co-ordinate system to accomplish the patient's first set-up using the video-based positioning system. We also introduce the marking of points on the surface of the body, which can be clearly imaged by computed tomography and are easily recognised from the photograph by the charge coupled device (CCD) camera. By comparing the real-time co-ordinates of the marked points with those obtained from the computed tomography, and with subsequent adjustment, the patient's first set-up in radiotherapy is realised with the video-based positioning system.