Diabetes and Weight Loss Are Associated With Malignancies in Patients With Intraductal Papillary Mucinous Neoplasms

BACKGROUND & AIMS

The role of diabetes in intraductal papillary mucinous neoplasms (IPMNs) is not known. We investigated the prevalence of diabetes among patients with resected IPMNs and the association between diabetes, clinical and morphological features, and high-grade dysplasia or invasive cancer.

METHODS

We collected clinical, pathology, laboratory, and demographic data from 134 patients who underwent pancreatic resection for IPMN from a referral center in Germany. We identified 50 patients with diabetes (37%).

RESULTS

Higher proportions of patients with diabetes were male and older, but did not have increased body mass index, compared to patients without diabetes. Diabetes was significantly associated with main-duct involvement (odds ratio [OR], 2.827; 95% CI, 1.059-7.546; P = .038) and high-grade dysplasia or invasive carcinoma (OR, 2.692; 95% CI, 1.283-5.651; P = .009). Risk of high-grade dysplasia or invasive cancer was even higher in patients with new-onset or worsening diabetes (OR, 4.615; 95% CI, 1.423-14.698; P = .011). Fifty-eight percent of patients (18/31) with weight loss at diagnosis had diabetes vs 32% of patients (31/97) without weight loss (P = .009). However, when the analysis was restricted to IPMNs with low-grade dysplasia, weight loss and diabetes were no longer associated (42% [5/12] vs 21% [9/44]; P = .133).

CONCLUSIONS

In patients with IPMNs, diabetes is associated with increased risk of main duct involvement and high-grade dysplasia or invasive carcinoma. Studies are needed to determine the relationship between diabetes and progression of IPMNs, which might lead to strategies for early detection and prevention of invasive cancer. Findings from this study should be considered in the guidelines for management of IPMN.

[Effects of the SARS-CoV-2 pandemic on surgery - a national cross-sectional study]

BACKGROUND AND AIMS

From the beginning of the SARS-CoV‑2 pandemic the German healthcare system focused on the treatment of COVID-19 patients. This was accompanied by the suspension of all elective operations. The aim of this study was to investigate the impact of the SARS-CoV‑2 pandemic on general and visceral surgery in university hospitals in Germany.

METHODS

This cross-sectional study was based on an anonymous survey, which was accessible online from 3 April 2020 to 17 April 2020 for the surgical departments of university hospitals in Germany. In total 73% (n = 29/40) of the hospitals participated in the survey.

RESULTS

Cooperation with the authorities and the hospital administration was generally considered adequate; however, only 3% (1/29) and 7% (2/29) fully agreed with the statement that the health authorities at the federal and state level, respectively, were supportive of general and visceral surgery. The hospital directors expect an average loss of revenues of 28 ± 16%. There was an average reduction in beds or operating room capacity of 38% and 45%, respectively. In addition, 11% of the medical personnel in general and visceral surgery were reallocated to other departments.

CONCLUSION

The SARS-CoV‑2 pandemic has a significant impact on academic general and visceral surgery in Germany. The reduction in beds and operating room capacity can lead to considerable delays in urgent surgical interventions and financial burdens in 2020 and subsequent years.

Histopathologic Response Is a Positive Predictor of Overall Survival in Patients Undergoing Neoadjuvant/Perioperative Chemotherapy for Locally Advanced Gastric or Gastroesophageal Junction Cancers-Analysis from a Large Single Center Cohort in Germany

There is conflicting evidence regarding the efficacy of neoadjuvant/perioperative chemotherapy (NCT) for gastro-esophageal cancer (GEC) on overall survival. This study aimed to analyze the outcomes of multimodal treatments in a large single center cohort. We performed a retrospective analysis of patients treated with NCT, followed by intended curative oncological surgery for locally advanced gastric cancer. Uni- and multivariate regression analysis were performed to identify the predictors of overall survival. From over 3000 patients, 702 eligible patients were analyzed. In the univariate analysis clinical stage, application of preoperative PLF, requirement of surgical extension, UICC-stage, grading, R-status, Lauren histotype, and HPR were the prognostic survival factors. In multivariate analysis PLF regimen, UICC-stages, R-status, Lauren histotype, and histopathologic regression (HPR) were significant predictors of overall survival. Overall HPR-rate was 26.9%. HPR was highest in the cT2cN0 stage (55.9%), and lowest in the cT3/4 cN+ stage (21.6%). FLOT demonstrated the highest HPR (37.5%). Independent predictors for HPR were the clinical stage and grading. Kaplan Meier analyses demonstrated significant survival benefits for the responding patients (p < 0.0001). HPR after NCT was an important prognostic factor to predict overall survival for locally advanced GEC. FLOT should be the preferred regimen in patients undergoing NCT ahead of surgery.

[Clinical Manifestations and Therapeutic Implications of Peritonitis]

Clinical Manifestations and Therapeutic Implications of Peritonitis Abstract. Peritonitis is a heterogenous disease, commonly classified into three types. Primary peritonitis, defined by the absence of another directly related intraabdominal abnormality, can often be treated conservatively and is thus distinguished from secondary peritonitis, which results from an independent diagnosis like the perforation or necrosis of an intraabdominal organ and usually requires surgical therapy. The more recently defined tertiary peritonitis is a form of secondary peritonitis that relapses or persists after 48 hours of adequate therapy with no surgically removable focus. This article addresses three important clinical manifestations of peritonitis and their therapeutic implications: spontaneous bacterial peritonitis as the mayor manifestation of primary peritonitis; postoperative peritonitis as a severe subform of secondary peritonitis; and peritoneal dialysis-associated peritonitis as a distinctive clinical picture.

Significance of tumour regression in lymph node metastases of gastric and gastro-oesophageal junction adenocarcinomas

The presence of lymph node (LN) metastases is one of the most important negative prognostic factors in upper gastrointestinal carcinomas. Tumour regression similar to that in primary tumours can be observed in LN metastases after neoadjuvant therapy. We evaluated the prognostic impact of histological regression in LNs in 480 adenocarcinomas of the stomach and gastro‐oesophageal junction after neoadjuvant chemotherapy. Regressive changes in LNs (nodular and/or hyaline fibrosis, sheets of foamy histiocytes or acellular mucin) were assessed by histology. In total, regressive changes were observed in 128 of 480 patients. LNs were categorised according to the absence or presence of both residual tumour and regressive changes (LN−/+ and Reg−/+). 139 cases were LN−/Reg−, 28 cases without viable LN metastases revealed regressive changes (LN−/Reg+), 100 of 313 cases with LN metastases showed regressive changes (LN+/Reg+), and 213 of 313 metastatic LN had no signs of regression (LN+/Reg−). Overall, LN/Reg categorisation correlated with overall survival with the best prognosis for LN−/Reg− and the worst prognosis for LN+/Reg− (p < 0.001). LN−/Reg+ cases had a nearly significant better outcome than LN+/Reg+ (p = 0.054) and the latter had a significantly better prognosis than LN+/Reg− (p = 0.01). The LN/Reg categorisation was also an independent prognostic factor in multivariate analysis (HR = 1.23; 95% CI 1.1–1.38; p < 0.001). We conclude that the presence of regressive changes after neoadjuvant treatment in LNs and LN metastases of gastric and gastro‐oesophageal junction cancers is a relevant prognostic factor.

[Is the discipline associated with self-confidence in handling rational antibiotic prescription? : Results from the MR2 study in German hospitals]

BACKGROUND

Besides public awareness and specialist knowledge and training of physicians, their self-confidence plays a key role for clinical decision-making in the respective area.

OBJECTIVE

This exploratory study investigated the influence of the discipline on differences in self-confidence in dealing with antibiotics and in the self-rated knowledge.

METHODS

In 2015 the multi-institutional reconnaissance of practice with multiresistant bacteria (MR2) questionnaire containing items on antibiotic prescription and multiresistant pathogens was sent out to 1061 physicians working in departments for internal medicine, general surgery, gynecology and obstetrics and urology. In 2017 a similar MR2 survey was sent to 1268 specialist and assistant physicians in anesthesiology in Germany. Besides demographic data 4 items on self-confidence in the use of antibiotic treatment and 11 items concerning self-rated knowledge about rational antibiotic therapy and multiresistant pathogens were included in the present analysis. Logistic regression analysis, the χ²-test and the Kruskal-Wallis test were used for statistical analysis of the influence of the discipline on these items.

RESULTS

The response rates were 43% (456 out of 1061) from the non-anesthetists and 56% (705 out of 1268) from the anesthetists. Of the non-anesthetists 44% and 57% of the anesthetists had had no advanced training on antibiotic stewardship during the year before the study. In the overall analysis anesthetists (mean±SD: 2.53±0.54) were significantly less self-confident about antibiotics than colleagues from other departments (internal medicine: 3.10±0.50, general surgery: 2.97±0.44, gynecology and obstetrics: 3.12±0.42 and urology: 3.15±0.44) in the unadjusted (all p<0.001) and adjusted comparison. The analysis of self-rated knowledge about rational antibiotic prescription showed similar results. Senior consultant status and advanced training in infectiology were significantly associated with self-confidence and self-rated knowledge about antibiotics.

CONCLUSION

Anesthetists showed significantly less self-confidence in dealing with antibiotics than colleagues from other disciplines. Advanced training on a rational prescription of antibiotics was associated with a greater self-confidence, so that the implementation of compulsory courses on rational antibiotic stewardship in the respective residency curriculum needs to be considered.

Prognostic implications of the eighth edition of the union for international cancer control - classification for gastric cancer patients from specialized treatment centers in Germany and Korea: A STOBE-Compliant large-scale cohort study

The validity of the 8th edition of the Union for International Cancer Control (UICC) staging system for gastric cancer has been evaluated only in Asian cohorts and not in European cohorts. The aim of this study was to evaluate the prognostic performance of the 8th edition of the UICC staging system in German and Korean cohorts independently and compare it with that of the 7th edition.A total of 6121 patients (526 from Germany and 5595 from Korea) who underwent upfront surgery for gastric cancer were retrospectively reclassified according to the 8th edition. Survival according to the UICC stages was estimated by the Kaplan-Meier method and compared by log-rank tests. A Cox proportional hazards model was fitted after adjusting for clinicopathological factors, and receiver operating characteristics analysis was conducted.The 8th edition showed significant differences in survival between each adjacent stage in the Korean cohort but not in the German cohort. Multivariate analyses revealed that the 8th edition staging was an independent prognostic factor, and its C-statistics were >0.76 in both German and Korean patients. The results were comparable to those observed with the UICC seventh edition (C-statistics was 0.768 vs 0.767 in the German cohort and 0.789 vs 0.785 in the Korean cohort for the 7th vs the 8th edition).The 8th edition showed prognostic value in predicting the survival of gastric cancer patients in both German and Korean cohorts. However, the predictive ability of the 8th and 7th edition was similar.

Prognostic implication of molecular subtypes and response to neoadjuvant chemotherapy in 760 gastric carcinomas: role of Epstein-Barr virus infection and high- and low-microsatellite instability

Epstein-Barr virus positivity (EBV(+)) and high-microsatellite instability (MSI-H) have been identified as molecular subgroups in gastric carcinoma. The aim of our study was to determine the prognostic and predictive relevance of these subgroups in the context of platinum/5-fluorouracil (5-FU) based preoperative chemotherapy (CTx). Additionally, we investigated the clinical relevance of the low-MSI (MSI-L) phenotype. We analysed 760 adenocarcinomas of the stomach or the gastro-oesophageal junction encompassing 143 biopsies before CTx and 617 resected tumours (291 without and 326 after CTx). EBV was determined by PCR and in situ hybridisation for selected cases. MSI was analysed by PCR using five microsatellite markers and classified as MSI-H and MSI-L. Frequencies of EBV(+), MSI-H and MSI-L in the biopsies before CTx were 4.2, 10.5 and 4.9% respectively. EBV(+) or MSI-H did not correlate with response, but MSI-L was associated with better response (p = 0.011). In the resected tumours, frequencies of EBV(+), MSI-H and MSI-L were 3.9, 9.6 and 4.5% respectively. Overall survival (OS) was significantly different in the non-CTx group (p = 0.014). Patients with EBV(+) tumours showed the best OS, followed by MSI-H. MSI-L was significantly associated with worse OS (hazard ratio [HR], 2.21; 95% confidence interval [CI], 1.21-4.04, p = 0.01). In the resected tumours after CTx, MSI-H was also associated with increased OS (HR, 0.54; 95% CI, 0.26-1.09, p = 0.085). In multivariable analysis, molecular classification was an independent prognostic factor in the completely resected (R0) non-CTx group (p = 0.035). In conclusion, MSI-H and EBV(+) are not predictive of response to neoadjuvant platinum/5-FU based CTx, but they are indicative of a good prognosis. In particular, MSI-H indicates a favourable prognosis irrespective of treatment with CTx. MSI-L predicts good response to CTx and its negative prognostic effect for patients treated with surgery alone suggests that MSI-L might help to identify patients with potentially high-benefit from preoperative CTx.

A novel pretherapeutic gene expression-based risk score for treatment guidance in gastric cancer

Background

Perioperative chemotherapy is an established treatment of advanced gastric cancer patients. Treatment selection is based on clinical staging (cT). We aimed to establish and validate a prognostic score including clinical and molecular factors, to optimize treatment decisions for these patients.

Patients and methods

We analyzed 626 carcinomas of the stomach and of the gastro-esophageal junction from two academic centers including primarily resected and pre-/perioperatively treated patients. Patients were divided into a training (N = 269) and validation (N = 357) set. Expression of 11 target genes was measured by quantitative PCR in resected tumors. A risk score to predict overall survival (OS) was generated and validated. Intra-tumoral heterogeneity was assessed by analyzing 50 tumor areas from 10 patients.

Results

A risk score including the expression of CCL5, CTNNB1, EXOSC3 and LZTR1 and the clinical parameters cT, tumor localization and histopathologic type suggested two groups with a significant difference in OS [hazard ratio (HR) 0.30; 95% confidence interval (CI) 0.17-0.52]. The risk score was successfully validated in an independent cohort (HR 0.32; 95% CI 0.21-0.51; P < 0.001) as well as in subgroups of primarily resected (HR 0.30; 95% CI 0.17-0.54; P < 0.001) and pre-/perioperatively treated patients (HR 0.37; 95% CI 0.17-0.81; P = 0.009). A significant difference in OS of high- and low-risk patients was also found in primarily resected patients with intestinal (HR 0.45; 95% CI 0.23-0.90; P = 0.020) and nonintestinal-type carcinomas (HR 0.1; 95% CI 0.02-0.42; P < 0.001). Intra-tumor heterogeneity analysis indicated a classification reliability of 95% for a supposed analysis of three biopsies.

Conclusion

The identified risk score could substantially contribute to an improved management of gastric cancer patients in the context of perioperative chemotherapy.

A microsatellite based multiplex PCR method for the detection of chromosomal instability in gastric cancer

Chromosomal instability (CIN) is a hallmark of distinct subclasses of tumours with potential clinical relevance. The aim of our study was to establish a time and cost effective method for the determination of CIN in gastric carcinomas (GC). We developed a microsatellite based multiplex PCR assay for the detection of allelic imbalances (AI) using experimentally defined marker specific threshold values for AI. The assay was tested in 90 formalin-fixed paraffin-embedded GC and results were compared in a subset of 30 carcinomas with the Affymetrix OncoScan assay, which detects copy number variations on genome wide level. The ratios of alterations detected by the two methods demonstrated a significant correlation (r = 0.88). Based on the results of the OncoScan assay, tumours were classified in CIN-High and CIN-Low and a threshold of the AI ratio determined with the PCR assay was defined. Accordingly, 20 of the 90 GC (22%) were CIN-Low and 70 (78%) CIN-High. A significant association of CIN-High was found with intestinal type tumours and proximal tumour localization. In conclusion, we established a PCR based method to categorize AI as surrogate for CIN, which is easy to perform and useful for the clarification of the clinical relevance of CIN in large GC cohorts.

The RENAISSANCE (AIO-FLOT5) trial: effect of chemotherapy alone vs. chemotherapy followed by surgical resection on survival and quality of life in patients with limited-metastatic adenocarcinoma of the stomach or esophagogastric junction - a phase III trial of the German AIO/CAO-V/CAOGI

Background

Historical data indicate that surgical resection may benefit select patients with metastatic gastric and gastroesophageal junction cancer. However, randomized clinical trials are lacking. The current RENAISSANCE trial addresses the potential benefits of surgical intervention in gastric and gastroesophageal junction cancer with limited metastases.

Methods

This is a prospective, multicenter, randomized, investigator-initiated phase III trial. Previously untreated patients with limited metastatic stage (retroperitoneal lymph node metastases only or a maximum of one incurable organ site that is potentially resectable or locally controllable with or without retroperitoneal lymph nodes) receive 4 cycles of FLOT chemotherapy alone or with trastuzumab if Her2+. Patients without disease progression after 4 cycles are randomized 1:1 to receive additional chemotherapy cycles or surgical resection of primary and metastases followed by subsequent chemotherapy. 271 patients are to be allocated to the trial, of which at least 176 patients will proceed to randomization. The primary endpoint is overall survival; main secondary endpoints are quality of life assessed by EORTC-QLQ-C30 questionnaire, progression free survival and surgical morbidity and mortality. Recruitment has already started; currently (Feb 2017) 22 patients have been enrolled.

Discussion

If the RENAISSANCE concept proves to be effective, this could potentially lead to a new standard of therapy. On the contrary, if the outcome is negative, patients with gastric or GEJ cancer and metastases will no longer be considered candidates for surgical intervention.

Trial registration

The article reports of a health care intervention on human participants and is registered on October 12, 2015 under ClinicalTrials.gov Identifier: NCT02578368; EudraCT: 2014–002665-30.

Fühlen sich Chirurgen gerüstet für die komplexen Fragestellungen im Umgang mit multiresistenten Erregern? – Ergebnisse der Fragebogenstudie MR2

Hintergrund Es liegen derzeit keine Untersuchungen darüber vor, welchen Kenntnisstand Chirurgen im Vergleich mit Nichtchirurgen über multiresistente Erreger (MRE) und den rationalen Einsatz von Antibiotika haben (Antibiotic Stewardship/ABS).

Methode Im Rahmen der MR2-Studie (Multiinstitutional Reconnaissance of practice with MultiResistant bacteria – a survey focussing on German hospitals) wurde ein Fragebogen mit 4 + 35 Punkten in 18 deutschen Krankenhäusern an Urologen, Internisten, Gynäkologen und Chirurgen verteilt. Mit multivariaten logistischen Regressionsmodellen wurde der Einfluss der Fachrichtung auf verschiedene prädeterminierte Endpunkte geprüft.

Ergebnisse Es konnten 456 auswertbare Fragebögen analysiert werden, wobei sich die Rücklaufquote bei Chirurgen (156/330, 47%) und Nichtchirurgen (300/731, 41%) nur insignifikant unterschied (p = 0,061). Chirurgen gaben in der Selbsteinschätzung im Vergleich mit Nichtchirurgen eine signifikant geringere Sicherheit bei der korrekten Wahl von Dosierung, Frequenz und Dauer der Antibiotikagabe (p = 0,005), der Entscheidung einer intravenösen vs. oralen Antibiotikaverordnung (p = 0,005) sowie der korrekten Interpretation der mikrobiologischen Befunde (p = 0,023) an. Sowohl Chirurgen als auch Nichtchirurgen schätzten ihr Wissen zu ABS als gering ein. Die Kenntnis der lokalen E.-coli-Resistenz gegen Ciprofloxacin unterschied sich zwischen Chirurgen und Nichtchirurgen nur insignifikant (27,6 vs. 35,3% waren in der richtigen Kategorie; p = 0,114), wobei 64% der Chirurgen diese lokalen Resistenzen unterschätzten. Beide Gruppen sahen in dem häufigen Einsatz von Breitspektrumantibiotika ein wesentliches Problem, das für die Zunahme von MRE verantwortlich ist. Andererseits wurde das gewählte Fallbeispiel einer stark symptomatischen Patientin mit unkomplizierter Harnwegsinfektion von beiden Gruppen ähnlich häufig mit einem Breitspektrumantibiotikum behandelt (34,0 vs. 29,3%; p = 0,331). Gemäß der multivariaten Modelle besuchten Chirurgen im Vergleich zu Nichtchirurgen in den letzten 12 Monaten nicht häufiger eine Weiterbildungsveranstaltung zum Thema der MRE/ABS und gaben auch keine bessere Qualität ihrer Klinikepikrisen hinsichtlich der exakten Auflistung von MRE an.

Schlussfolgerungen Es sollten in den Kliniken obligat ABS-Programme implementiert werden, die u. a. eine regelmäßige Fortbildung der Kollegen unabhängig von ihrer Fachrichtungen vorsehen.

Minimally invasive surgery for gastric cancer: A comparison between robotic, laparoscopic and open surgery

AIM

To investigate the role of minimally invasive surgery for gastric cancer and determine surgical, clinical, and oncological outcomes.

METHODS

This is a propensity score-matched case-control study, comparing three treatment arms: robotic gastrectomy (RG), laparoscopic gastrectomy (LG), open gastrectomy (OG). Data collection started after sharing a specific study protocol. Data were recorded through a tailored and protected web-based system. Primary outcomes: harvested lymph nodes, estimated blood loss, hospital stay, complications rate. Among the secondary outcomes, there are: operative time, R0 resections, POD of mobilization, POD of starting liquid diet and soft solid diet. The analysis includes the evaluation of type and grade of postoperative complications. Detailed information of anastomotic leakages is also provided.

RESULTS

The present analysis was carried out of 1026 gastrectomies. To guarantee homogenous distribution of cases, patients in the RG, LG and OG groups were 1:1:2 matched using a propensity score analysis with a caliper = 0.2. The successful matching resulted in a total sample of 604 patients (RG = 151; LG = 151; OG = 302). The three groups showed no differences in all baseline patients characteristics, type of surgery (P = 0.42) and stage of the disease (P = 0.16). Intraoperative blood loss was significantly lower in the LG (95.93 ± 119.22) and RG (117.91 ± 68.11) groups compared to the OG (127.26 ± 79.50, P = 0.002). The mean number of retrieved lymph nodes was similar between the RG (27.78 ± 11.45), LG (24.58 ± 13.56) and OG (25.82 ± 12.07) approach. A benefit in favor of the minimally invasive approaches was found in the length of hospital stay (P < 0.0001). A similar complications rate was found (P = 0.13). The leakage rate was not different (P = 0.78) between groups.

CONCLUSION

Laparoscopic and robotic surgery can be safely performed and proposed as possible alternative to open surgery. The main highlighted benefit is a faster postoperative functional recovery.

Macroscopy predicts tumor progression in gastric cancer: A retrospective patho-historical analysis based on Napoleon Bonaparte's autopsy report

BACKGROUND

The cause of Napoleon Bonaparte's death remains controversial. Originally suggested to be gastric cancer, whether this was truly neoplastic or a benign lesion has been recently debated.

AIMS

To interpret findings of original autopsy reports in light of the current knowledge of gastric cancer and to highlight the significance of accurate macroscopy in modern-day medicine.

METHODS

Using original autopsy documents, endoscopic images and data from current literature, Napoleon's gastric situation was reconstructed. In a multicenter collection of 2071 gastric cancer specimens, the relationship between tumor size and features of tumor progression was assessed.

RESULTS

Greater tumor size was associated with advanced pT, nodal metastases and Borrmann types 3-4 (p<0.001). The best cut-off for predicting pT3-4 tumors was 6.5cm (AUC 0.8; OR 1.397, 95% CI 1.35-1.446), and 6cm for lymph node metastases (AUC 0.775; OR 1.389, 95% CI 1.338-1.442). The 6cm cut-off of had a positive predictive value of 0.820 for nodal metastases and a negative predictive value of 0.880 for distant metastases.

CONCLUSION

This analysis combines Napoleon's autopsy with present-day knowledge to support gastric cancer as his terminal illness and emphasizes the role of macroscopy, which may provide valuable information on gastric cancer progression and aid patient management.

Perioperative transfusion of leukocyte depleted blood products in gastric cancer patients negatively influences oncologic outcome: A retrospective propensity score weighted analysis on 610 curatively resected gastric cancer patients

The influence of perioperative transfusion (PT) on outcome following surgery for gastric cancer (GC) remains controversial, with randomized trials lacking and observational series confounded by patient risk factors. This analysis determines the association between reception of leukocyte-depleted blood products and post-operative survival for GC.Data from 610 patients who underwent curative surgery for GC in a German tertiary care clinic from 2001 to 2013 were included. Kaplan-Meier survival curves and Cox proportional hazards regression were applied to determine the association of PT and clinical and patient risk factors for overall and relapse-free survival. Propensity score analysis was performed to adjust for observational biases in reception of PT.Higher Union International Contre le Cancer/American Joint Committee on Cancer (UICC/AJCC)-stages (P <0.001), postoperative complications and severity according to the Clavien-Dindo (CD) classification (P <0.001), PT (P = 0.02), higher age (P <0.001), and neoadjuvant chemotherapy (P <0.001) were related to increased mortality rates. Higher UICC-stages (P <0.001), neoadjuvant chemotherapy (P <0.001), and type of surgery (P = 0.02) were independently associated with increased relapse rates. Patients were more likely to receive PT with higher age (P = 0.05), surgical extension to adjacent organs/structures (P = 0.002), tumor location (P = 0.003), and female gender (P = 0.03). In the adjusted propensity score weighted analysis, PT remained associated with an increased risk of death (hazard ratio (HR): 1.31, 95% CI: 1.01-1.69, P = 0.04).Because of the association of PT with negative influence on patient survival following resection for GC, risks from application of blood products should be weighed against the potential benefits.

Outcome of gastric cancer in the elderly: a population-based evaluation of the Munich Cancer Registry

BACKGROUND

Gastric cancer accounts for 5 % of cancer deaths. Proportions of older stomach cancer patients are increasing. Despite the still poor prognosis, standardised treatment has achieved improvements; nonetheless it is questionable whether all age groups have benefitted. Age and outcome need to be examined in a population-based setting.

METHODS

Analyses included Munich Cancer Registry (MCR) data from 8601 invasive gastric cancer patients, diagnosed between 1998 and 2012. Tumour and therapy characteristics and outcome were analysed by two age groups (<70 vs. ≥70 years). Survival was analysed using the Kaplan-Meier method and relative survival was computed as an estimation for cancer-specific survival. Additional landmark analyses were conducted by calculating conditional survival of patients who survived more than 6 months.

RESULTS

Fifty-nine per cent of the cohort were ≥70 years old. These patients had tumours with a slightly better prognosis and were treated with less radical surgery and adjuvant therapy than younger patients. The 5-year relative survival was 40 % for the youngest (<50 years) and 23 % for the oldest patients (≥80 years). Survival differences were diminished or eliminated after landmark analyses: The 5-year relative survival in age groups 50-59, 60-69 and 70-79 years was comparable (between 48 and 49.6 %) and slightly worse in the youngest and oldest (45 %), which may be explained by more aggressive tumours and effects of cellular senescence, respectively.

CONCLUSION

The treatment and care of elderly gastric cancer patients in the MCR catchment area seems appropriate: if a patient's general condition allows oncologic resection and chemotherapy, it is conducted and the result is comparable between age groups.

Ticlopidine-Induced Cholestatic Inflammatory Hepatitis: New Insights into Pathogenetic Mechanisms of Drug-Related Hepatotoxicity

In immune-induced liver damage the reactive metabolites may covalently bind or alter liver proteins such as cytochrome P450 enzymes, which leads to activation of the immune system. Ticlopidine is an inhibitor of CYP2C19 human liver cytochrome. We attempted to analyse the role of cytochrome CYP2C19 genetic polymorphism in the development of ticlopidine-induced cholestatic hepatitis and relate it with the specific immune reactivity to ticlopidine, different cytokine profiles and induction of necrosis and apoptosis within the liver tissue. Three patients with cholestatic hepatitis with ticlopidine-related liver injury, 3 patients with obstructive jaundice due to choledocholithiasis, 3 patients treated with ticlopidine without liver damage and 10 healthy individuals were studied. Genotyping for the following genotypes CYP2C19 (CYP2C19*1–3) were tested after polymerase chain reaction (PCR) by restriction fragment length polymorphism (RFLP) with Sma I and BamH I enzymes. The T cell reactivity to ticlopidine was analysed by T cell proliferation assay in PBMC against ticlopidine, tetanus toxoid antigen and phytohemagglutinin on days 0, 90, 150 and 210 after therapy withdrawal. The serum levels of INF-γ, IL-2, IL-4, IL-10, TNF-α, sFas and sFasL were measured by ELISA at the same time points. Apoptosis was analysed by TUNEL assay. All patients with cholestatic hepatitis had “slow metabolizers” genotypes in contrast to other groups. The T cell reactivity to ticlopidine was present only in all the cholestatic hepatitis patients together with substantial decrease in levels of INF-γ, IL-2 and TNF-α during all of the follow-up period. Cholestatic hepatitis patients had high apoptotic index in TUNEL assay. The genetic polymorphism of the cytochrome CYP2C19 gene is directly responsible for the susceptibility to the ticlopidine-induced liver damage. Th1 type of immune reactivity plays the key role in the pathogenesis of drug-induced hepatotoxicity.

Cisplatin and oxaliplatin surface contamination in intensive care units (ICUs) and hospital wards during attendance of HIPEC patients

PURPOSE

The aim of this pilot study was to evaluate surface contamination by platinum drugs in the environment of patients in ICUs and wards treated by hyperthermic intraperitoneal chemotherapy (HIPEC).

METHODS

The monitoring included 12 HIPEC treatments from four hospitals during the following 3 days after perfusion. A total of 33 urine and 33 drainage fluids from HIPEC patients and 160 wipe samples from several surfaces (urine/drainage bags, floors, gloves) were taken during the study period.

RESULTS

In urine, the highest platinum concentrations were measured on the first day after perfusion. Median platinum concentrations were 1260 ng/ml for patients after cisplatin perfusion and 11,000 ng/ml for oxaliplatin treatment. Concentrations decreased until day three to 413 ng/ml cisplatin and 529 ng/ml oxaliplatin, respectively. In drainage liquids, platinum concentrations were generally lower. Platinum concentrations from surfaces of bags and floors ranged from 0.01 to 439 pg/cm(2) (median: urine bag 2.77 pg/cm(2), drainage bag 0.22 pg/cm(2), floor left 0.14 pg/cm(2), floor right 0.24 pg/cm(2)), with the highest contamination found on the outer surface of the urine bags. Samples from nurses' protective gloves ranged between 0.03 and 12 pg/cm(2) (median: 0.2 pg/cm(2)).

CONCLUSIONS

High platinum-drug concentrations in urine and drainage liquids are the main source of contamination. Therefore, safe handling of these liquids is the best way to avoid cross-contamination on surfaces in wards and ICUs. Our results show that it is possible to take care of HIPEC patients without high contaminations during the first 3 days.

Gastric Adenocarcinomas Express the Glycosphingolipid Gb3/CD77: Targeting of Gastric Cancer Cells with Shiga Toxin B-Subunit

The B-subunit of the bacterial Shiga toxin (STxB), which is nontoxic and has low immunogenicity, can be used for tumor targeting of breast, colon, and pancreatic cancer. Here, we tested whether human gastric cancers, which are among the most aggressive tumor entities, express the cellular receptor of Shiga toxin, the glycosphingolipid globotriaosylceramide (Gb3/CD77). The majority of cases showed an extensive staining for Gb3 (36/50 cases, 72%), as evidenced on tissue sections of surgically resected specimen. Gb3 expression was detected independent of type (diffuse/intestinal), and was negatively correlated to increasing tumor-node-metastasis stages (P = 0.0385), as well as with markers for senescence. Gb3 expression in nondiseased gastric mucosa was restricted to chief and parietal cells at the bottom of the gastric glands, and was not elevated in endoscopic samples of gastritis (n = 10). Gb3 expression in established cell lines of gastric carcinoma was heterogeneous, with 6 of 10 lines being positive, evidenced by flow cytometry. STxB was taken up rapidly by live Gb3-positive gastric cancer cells, following the intracellular retrograde transport route, avoiding lysosomes and rapidly reaching the Golgi apparatus and the endoplasmic reticulum. Treatment of the Gb3-expressing gastric carcinoma cell line St3051 with STxB coupled to SN38, the active metabolite of the topoisomerase type I inhibitor irinotecan, resulted in >100-fold increased cytotoxicity, as compared with irinotecan alone. No cytotoxicity was observed on gastric cancer cell lines lacking Gb3 expression, demonstrating receptor specificity of the STxB-SN38 compound. Thus, STxB is a highly specific transport vehicle for cytotoxic agents in gastric carcinoma. Mol Cancer Ther; 15(5); 1008-17. ©2016 AACR.