Trans-arterial chemoembolization (TACE) of liver metastases (LM) from colorectal cancer (CRC) adopting irinotecan-eluting beads: Results of a phase II clinical study

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Background: Patients with LM from CRC have a poor prognosis with survival rates of 31% at 1 year and 2.6% at 3 years. Surgery is feasible in a minority of patients and most them received systemic chemotherapy. Irinotecan (IRI) is an active drug in the treatment of advanced CRC. The advantage of delivering chemotherapy by hepatic arterial infusion is the achievement of high-dose of the drug in the target . TACE is a combination of local drug infusion with selective embolization of the feeding arteries of the liver metastases. DC bead is a new embolic microsphere product that can be loaded with IRI before administration in TACE. The purpose of this study is to assess the safety and efficacy of this new embolic microspheres IRI loaded and administered as TACE in patients with LM from CRC. Methods: 35 patients with LM from CRC Stage II-III Pettavel Classification pretreated were observed from Nov 2005 to Dec 2006. 25 gave their written consent to be treated with one o more cycles of TACE. Imaging was performed before, immediately and 4 weeks after TACE to determine response and the need for further treatment. Each patient received i.v hydration, antibiotics, analgesics and medications against nausea before TACE. Survival was calculated with Kaplan-Meier method. Results: 60 cycles were administered. We observed a Response Rate of 80% by RECIST criteria. A month after TACE we had a reduction of +50% of CEA in 60% of patients. A reduction of the lesional contrast enhancement of the metastases was observed in 80% of patients. 22 patients are alive, with a median survival of 9.5 months (range 6–13). Median duration response was 16 weeks (range 12–25). 14 cases experienced WHO Grade 2 right upper quadrant pain (RUQP) and 11 cases Grade 3 lasting 12 hours (range 3–30). All patients had 2 days Grade 2 fever (range 1–7), ten had 3 days Grade 3. 20 have had Grade 2 nausea and vomiting for 6 hours (range 4–29). No alopecia or marrow toxicity was reported. Conclusions: DC bead -TACE was feasible and effective in patients with LM from CRC. RUQP seems the most significant toxic event and needs analgesic therapy. No survival data are conclusive because the follow up is short. DC bead of IRI 100 mgr-TACE myght be an appropriate palliative therapy for these patients.

No significant financial relationships to disclose.

18F-FDG PET/CT in the assessment of carcinoma of unknown primary origin

PURPOSE

Metastatic cancers of unknown primary origin are characterised by a poor prognosis, with a survival rate from diagnosis of approximately 12 months. Conventional radiological imaging allows detection of 20%-27% of primary cancers, whereas the detection rate with positron emission tomography (PET) is 24%-40%. The aim of this study was to assess the role of 18F-fluorodeoxyglucose (FDG) PET/computed tomography (CT) in the identification of occult primary cancers.

MATERIALS AND METHODS

The study population consisted of 38 consecutive patients with histologically proven metastatic disease and negative or nonconclusive conventional diagnostic procedures. All patients were studied by 18F-FDG PET performed according to the standard procedure (6 h of fasting, intravenous injection of 370 MBq 18F-FDG, and image acquisition with a PET/CT scanner for 4 min per bed position).

RESULTS

18F-FDG-PET/CT detected the occult primary cancer in 20 cases (53%), showing higher sensitivity than that reported for any other imaging modality, including PET.

CONCLUSIONS

The encouraging results, if validated by larger series, support the use of PET/CT in patients with carcinoma of unknown primary origin and negative conventional imaging results.

Hypoxic abdominal stop-flow perfusion in the treatment of advanced pancreatic cancer: a phase II evaluation/trial

In the past decade, some authors have reported objective responses and prolonged median survival times using hypoxic abdominal perfusion (HAP) for the treatment of advanced pancreatic cancer. However, these promising results have not been confirmed by others, making it difficult to define the effectiveness of this loco-regional chemotherapy. The aim of this study, therefore, was to evaluate the response rate, time to disease progression and overall survival following HAP treatment of 22 consecutive patients with advanced pancreatic tumors. Within the period from 1999 to 2003, 22 patients with histological diagnosis of unresectable stage III/IV pancreatic cancer, not responsive to systemic chemotherapy, were treated with mitomycin C 30mg/m(2) and cisplatin 60mg/m(2) by HAP (stop flow technique). Immediately after perfusion, hemofiltration was performed to reduce systemic side toxic effects. Responses were assessed by CT-scan 30days from the end of treatment. Minor or partial responses were confirmed by a second CT-scan 4weeks later. Following 26 treatment cycles no death or technical complications were recorded; four patients (18.2%) achieved a partial response, 2 (9.1%) a minimal response and 13 (59.1%) stable disease. The remaining 3 patients (13.6%) showed progression of the disease. The median time to disease progression was 3 months (range 1-10). The median survival time from the start of regional chemotherapy was 6 months (range 1.9-16), with a 1-year survival rate of 9%. Our data show that HAP is a relatively effective second-line treatment for advanced stage pancreatic cancer with a low complication rate. We do not concur with the opinion of others that HAP is an inactive treatment approach. However, taking into account the invasiveness of this procedure, and associated morbidity and cost, HAP would not appear to be preferable to less invasive loco-regional chemotherapeutic alternatives.

Ten years experience in the treatment of pseudomyxoma peritonei by cytoreduction, peritonectomy and semi-closed hyperthermic antiblastic peritoneal perfusion

BACKGROUND

In the literature good results have been reported for the treatment of Pseudomyxoma peritonei (PMP) by cytoreduction, peritonectomy and hyperthermic antiblastic peritoneal perfusion (H.A.P.P.). Forty-eight patients affected by PMP have been treated with this technique over the past ten years.

PATIENTS AND METHODS

Peritoneal perfusion has been performed with the original semiclosed tecnique after complete surgical cytoreduction in 188 patients affected by peritoneal carcinomatosis. In 48 of the cases the patients were affected from PMP. Aggressive surgical cytoreduction was performed with multiple visceral resections and peritonectomies.

RESULTS

Seventeen patients (38%) presented major perioperative complications, and in five cases the reoperation of the patient was required. In spite of this high complication rate, there was no perioperative mortality. The results of the Kaplan-Meier 5- and 10-year survival analysis, were 94% and 82%, respectively, with a disease-free survival of 80% at 5 years and 70% at 10 years. Thirty-nine patients (81.2%) had no evidence of disease at follow-up (range 1-120 months).

DISCUSSION

Up to date, the most effective treatment for PMP has been aggressive cytoreduction plus H.A.P.P.

Thalidomide plus monthly high-dose dexamethasone in chemorefractory myeloma. Results of a phase II clinical study

Thalidomide is a potent anti-myeloma drug which can produce up to a 30-50% overall response rate (ORR) in pre-treated, chemorefractory multiple myeloma. Most authors agree with using 200 mg/daily with associated high dose dexamethasone (40 mg/daily x 4 days, 3 times monthly) considering lower doses investigational. We report our experience using thalidomide 100 mg/daily plus dexamethasone 40 mg/daily once a month, in 27 pre-treated patients. Thalidomide dose excalation and/or association with other drugs were established on the basis of the patient's response. Median age was 69 years (range 50-83 years) and 16 male and 11 female patients were treated. All patients had received more than 1 treatment line (range 1-5). Thalidomide was increased up to 300 mg/daily in 10 patients and 1 patient received up to 400 mg/daily. Two patients were not evaluable because of early death, 1 did not tolerate thalidomide because of pulmonary and neurological side-effects. Sixteen patients responded to this treatment, with an ORR of 66%. The combination of low-dose thalidomide plus monthly high-dose dexamethasone in chemorefractory myeloma showed interesting palliative results. According to our data, increasing thalidomide dosage and/or adding further drugs does not generally produce significant improvement.

Níveis de fibra em detergente neutro na dieta de cordeiros: consumo, digestibilidade e fermentação ruminal

Foram utilizados oito cordeiros castrados (35,0±6,0kg peso vivo) em um delineamento duplo quadrado latino 4 <FONT FACE=Symbol>´</FONT> 4 para avaliar o efeito de quatro níveis de fibra em detergente neutro (FDN) na dieta (25, 31, 37 e 43% da matéria seca (MS)) sobre o consumo e parâmetros digestivos. O consumo de nitrogênio (N) variou de forma quadrática; o de MS, matéria orgânica (MO) e energia diminuíram (P<0,05) e de FDN aumentou (P<0,01) linearmente com o aumento de fibra na dieta. A digestibilidade da FDN e do N, assim como o pH e as concentrações de peptídeos no fluído ruminal foram similares em todos os tratamentos. A digestibilidade aparente da MS, da MO e da energia, assim como as concentrações ruminais de açúcares diminuíram linearmente (P<0,01) e a síntese de proteína microbiana ruminal, as concentrações ruminais de amônia e de aminoácidos variaram quadraticamente (P<0,05) com o aumento do teor de FDN das dietas. A redução do consumo e da digestibilidade foram mais evidentes somente pela inclusão do nível mais alto de FDN (43%) e, sob o aspecto nutricional, a inclusão em torno de 30% de FDN representa o nível mais adequado para formulação de dietas a base de silagem de sorgo e concentrado oferecido a cordeiros confinados.

Trans-arterial chemoembolization (TACE) of liver metastases from colorectal cancer using irinotecan-eluting beads: preliminary results

PURPOSE

The purpose of the study was to evalutate the feasibility of irinotecan drug-eluting beads (DC Bead) administered as trans-arterial chemoembolization (TACE) in patients with liver metastases from colorectal cancer (CRC).

PATIENTS AND METHODS

Ten patients with liver metastases from CRC were treated with TACE adopting irinotecan-eluting beads at a dose of 100 mg every 3 weeks. Computed Tomography (CT) was performed 24h before and after TACE.

RESULTS

TACE with irinotecan eluting beads was found to be feasible and well-tolerated. Right upper quadrant pain (RUQP) lasting 4 days (range 2-7) was reported by all the patients. After 30 days, a reduction >50% of CEA levels and of the lesional contrast enhancement was observed in all the patients.

CONCLUSION

Irinotecan drug-eluting beads administered as TACE were shown to be active and safe in patients with liver metastases from CRC.

Abdominal and pelvic stop-flow chemotherapy. Effect of chemotherapeutic agents and tissue ischemia on rectoanal pressures

In hypoxic stop-flow chemoperfusion high doses of chemotherapeutic agents are almost directly administered to locally advanced tumors without risking significant systemic toxicity, although chemotherapy-induced neurotoxicity is still a problem. The aim of the study was to assess rectoanal motility and sensation before, during and after abdominal and pelvic stop-flow chemotherapy using the methods of stationary and ambulatory manometry. Stationary rectoanal manometry was performed within 24 hrs before and repeated 48 hrs after stop-flow chemotherapy in 7 consecutive patients with a history of locally advanced or recurrent abdominal and pelvic tumors. Anal sphincter resting and squeeze pressures, rectal sensitivity, rectoanal inhibitory reflex and rectal volumes at which temporary and permanent urge to defecate were reported were examined. Rectal volume associated with leak of rectal contents and rectal compliance were also assessed. Intraoperatively, changes in rectal and anal resting pressures before, during and after occlusion of the vessels and after administration of chemotherapeutic agent were as well recorded, analyzed and interpreted using ambulatory manometry. Induction of anesthesia reduced distal and proximal anal resting pressures. Vascular occlusion further and dramatically decreased resting pressures at all levels, which were fully recovered after re-establishing local blood circulation and for the rest of the recording period. Intraoperative administration of chemotherapy did not further affect anal resting pressures during or after hypoxia. No significant changes in rectoanal motility and sensation were detected on the 48 hrs postoperative assessment as compared to the preoperative state. Tissue hypoxia induced by vascular occlusion during stop-flow chemotherapy procedure, seems to be the only factor leading to a dramatic drop of anal pressures. Anal pressures fully recover after reperfusion of the isolated area. Furthermore, anorectal motility and sensation are not affected by any direct or indirect toxic action of the chemotherapeutic agents.

Intra-arterial hepatic fotemustine for the treatment of liver metastases from uveal melanoma: experience in 101 patients

BACKGROUND

Exclusive liver metastases occur in up to 40% of patients with uveal melanoma associated with a median survival of 2-7 months. Single agent response rates with commonly available chemotherapy are below 10%. We have investigated the use of fotemustine via direct intra-arterial hepatic (i.a.h.) administration in patients with uveal melanoma metastases.

PATIENTS AND METHODS

A total of 101 patients from seven centers were treated with i.a.h. fotemustine, administered intra-arterially weekly for a 4-week induction period, and then as a maintenance treatment every 3 weeks until disease progression, unacceptable toxicity or patient refusal.

RESULTS

A median of eight fotemustine infusions per patient were delivered (range 1-26). Catheter related complications occurred in 23% of patients; however, this required treatment discontinuation in only 10% of the patients. The overall response rate was 36% with a median overall survival of 15 months and a 2-year survival rate of 29%. LDH, time between diagnosis and treatment start and gender were significant predictors of survival.

CONCLUSIONS

Locoregional treatment with fotemustine is well tolerated and seems to improve outcome of this poor prognosis patient population. Median survival rates are among the longest reported and one-third of the patients are still alive at 2 years.

[Complications of cytoreductive surgery associated with intraperitoneal chemohyperthermia: prevention and treatment]

New approach to peritoneal carcinomatosis combining cytoreductive surgery and hypertermic intraperitoneal chemotherapy suggest improved survival when it is possible to achieve a complete cytoreduction. In this study we consider the major complications related to this procedure and purpose our approach for their prevention and treatment.

FDG-PET in the management of germ cell tumor

Germ cell tumor is the most common malignancy in young men. The cure rate of these patients has tremendously increased in the cisplatin era, and recent results have indicated that the management of patients with GCT is still improving. The use of FDG-PET in the management of patients with GCT has been recently investigated. This report attempts to comprehensively review new advances and delineate the potential applications of FDG-PET in GCT.

[Cytoreduction and intraoperative peritoneal chemohyperthermia in carcinomatosis from colonic carcinoma and in peritoneal pseudomyxoma]

New approach in treatment of peritoneal carcinomatosis combining cytoreductive surgery and intraperitoneal chemotherapy suggests improved survival when it is possible to achieve a complete cytoreduction. In this study we consider the carcinomatosis from colorectal and appendiceal adenocarcinoma. In all cases, patients in whom cytoreductive surgery was complete had a median survival much longer compared with patients in whom was not possible and, as perfusion works on minimal residual disease, peritonectomy is the only surgical technique that aim at total removal of parietal and visceral peritoneal lesions.

[Sentinel lymph nodes in early gastric cancer: preliminary feasibility study]

From January to December 2004, 8 patients with pre-operative diagnosis of early gastric cancer (EGC) and no nodal involvement were submitted to sentinel node biopsy using the dual mapping procedure with endoscopic blue dye and 99mTc radio-colloid injection. All the patients underwent standard radical gastrectomy and D2 lymphadenectomy. The resected nodes were evaluated by routine (hematoxylin-eosin) histopathological examination; the sentinel (blue or hot) nodes in addition were evaluated with immunohistochemistry for cytokeratin. The preliminary results and perspectives for feasibility of sentinel node biopsy and its accuracy in predicting the nodal status in EGC are discussed.