Treatment of PTLD with rituximab and CHOP reduces the risk of renal graft impairment after reduction of immunosuppression

We addressed the effect of post-transplant lymphoproliferative disorder (PTLD) treatment with rituximab monotherapy or CHOP-based chemotherapy (+/- rituximab) after upfront immunosuppression reduction (IR) on renal graft function in a longitudinal analysis of 58 renal transplant recipients with PTLD and 610 renal transplant controls. Changes in the estimated glomerular filtration rate over time were calculated from a total of 6933 creatinine measurements over a period of >1 year using a linear mixed model with random and fixed effects. Renal graft function significantly improved with treatment of PTLD, especially in the chemotherapy subgroup. Patients treated with IR+chemotherapy +/- rituximab had a noninferior graft function compared with untreated controls suggesting that the negative impact of IR on the renal graft function can be fully compensated by the immunosuppressive effect of CHOP. The immunosuppressive effect of single agent rituximab may partially compensate the negative impact of IR on the graft function. Thus, it is possible to reduce immunosuppression when using chemotherapy to treat PTLD.

Regional pelvic hyperthermia as an adjunct to chemotherapy (oxaliplatin, folinic acid, 5-fluorouracil) in pre-irradiated patients with locally recurrent rectal cancer: a pilot study

The aim of this study was to evaluate the feasibility and toxicity of a novel hyperthermic chemotherapy approach for patients with locally recurrent adenocarcinoma of the rectum. All patients were pre-irradiated (> or = 45 Gy) and had histologically proven pelvic recurrence. Hyperthermic chemotherapy was applied according to a modified 'OFF'-schedule with weekly infusions of 43 mg/m2 of oxaliplatin (i.v., 120 min), 500 mg/m2 of folinic acid (i.v., 120 min) and 2.6 g/m2 of continuous infusional 5-fluorouracil (24 h) for 6 consecutive weeks. Oxaliplatin was started in parallel to pelvic radiofrequency hyperthermia that was provided by the BSD 2000-system. A total of 67 applications were administered to nine patients and were well tolerated. A total of 55/67 (82%) chemotherapy courses were applied without dose-reduction. In 62/67 (93%) hyperthermia sessions, a treatment time of > 60 min was maintained. Tolerated power levels were on average 600 W and, thus, slightly lower than those described in curative pelvic hyperthermia schedules. Eight out of 10 episodes of severe (WHO III degrees) toxicity represented typical side-effects of the chemotherapy given (nausea n = 4, diarrhoea n = 3, neuropathy n = 1). Two severe adverse events were firstly attributable to hyperthermia (haematuria, n = 1; deterioration of a decubital ulcer, n = 1). No patient suffered WHO-disease progression during the treatment period. Two patients achieved a partial remission. It is concluded that hyperthermic chemotherapy with oxaliplatin, folinic acid and 5-FU is feasible on an outpatient basis. Overall toxicity was moderate, although hyperthermia may add side-effects to this approach. Results, moreover, suggest a relevant palliative effect in patients with pre-irradiated pelvic recurrence of rectal cancer.

A prospective, randomized trial of chemotherapy with or without the low molecular weight heparin (LMWH) enoxaparin in patients (pts) with advanced pancreatic cancer (APC): Results of the CONKO 004 trial

LBA4506

Background: The course of pts with APC is often complicated by venous thromboembolic events (VTE). Anticoagulation therapy with LMWH may prevent VTE and is under discussion to improve overall survival (OS) in cancer. Based on our previous pilot study (Hilbig et al, Onkologie 2005;28(suppl 3)) indicating the safety and feasibility to the addition of the LMWH enoxaparin to chemotherapy in pts with APC we started the open, prospective, randomized, multicenter study to investigate the role of enoxaparin in these pts. Methods: Primary endpoint was the reduction of symptomatic VTE (sVTE) from an expected 10% to 3% within the first 12 weeks of treatment. The occurrence of sVTE (secured by an independent, blinded event review board) in 24 pts was calculated to be necessary in order to define the role of enoxaparin in decreasing the risk of VTE. Toxicity, time to progression (TTP), and OS were among the secondary endpoints of the study approved by the ethics committees of the participating centers. VTE-naive and chemotherapy-naive pts with histologically or cytologically confirmed APC were randomized to receive or not to receive additional LMWH (enoxaparin 1mg/kg once daily) starting in parallel to palliative systemic chemotherapy. Results: In January 2009 after recruitment of 312 pts the study was closed. There were 22 sVTE in 152 pts of the observation group (O) and 8 in 160 pts of the enoxaparin group (E). ITT and PP analyses demonstrated significant risk reductions from 14.5% to 5.0% (65% RRR) and 14.5% to 3.8% (74% RRR) for E, respectively. Major bleeding events were 9.9% for O and 6.3% for E (ITT; n.s.). In each group there was one tumor-related fatal hemorrhage. Preliminary data show no difference in TTP (O:19 vs. E:22 w) and OS (O:29 vs. E:31 w). Conclusions: Enoxaparin is effective and safe in the primary prevention of sVTE applied in parallel with cytotoxic chemotherapy in pts with APC. Final results on TTP and OS are pending.

No significant financial relationships to disclose.

A prospective, randomized trial of chemotherapy with or without the low molecular weight heparin (LMWH) enoxaparin in patients (pts) with advanced pancreatic cancer (APC): Results of the CONKO 004 trial

LBA4506

The full, final text of this abstract will be available in Part II of the 2009 ASCO Annual Meeting Proceedings, distributed onsite at the Meeting on May 30, 2009, and as a supplement to the June 20, 2009, issue of the Journal of Clinical Oncology.

No significant financial relationships to disclose.

[Acquired coagulopathies]

Acquired coagulopathies regularly result from underlying diseases such as liver failure or sepsis. Optimal treatment of these underlying diseases defines longterm prognosis. In a few coagulopathies, such as immunocoagulopathies, in a relevant portion of patients an underlying disease cannot be identified. Therapeutic modulation of haemostasis aiming at the prevention of fatal bleeding or thromboembolism is able to improve the prognosis of patients with acquired coagulopathies. Most often this is the result of individualized, lab-controlled treatments, which are difficult to study. Within the last years the role of therapeutic modulation of haemostasis to reduce mortality was successfully studied for the first time in the frame of randomized placebo-controlled phase III studies.

A Clinical Pilot Study of Fresh Frozen Plasma versus Human Albumin in Paediatric Craniofacial Repair

Paediatric craniofacial surgery (pCFS) regularly requires transfusion of packed red blood cells (pRBC). In this clinical pilot study two different transfusion regimens were prospectively compared concerning pRBC transfusions, postoperative bleeding and other clinical parameters. Thirty infants (aged < 12 months) scheduled for pCFS were assigned to receive fresh frozen plasma (FFP-group, n = 15) or 5% human albumin (HA-group, n = 15) during the entire surgical procedure. Perioperative amounts of pRBC, postoperative bleeding, major complications, duration of stay in the intensive care unit and overall hospital stay were compared. Differences in pRBC transfusions, postoperative bleeding, and duration of intensive care unit stay were not significant and no major complications occurred in either group. A significantly shorter overall hospital stay was observed in favour of the FFP-group. Volume replacement during pCFS can be safely performed with both applied protocols. Our data do not demonstrate a major advantage for FFP use, but further evaluation is necessary.

Erworbene Koagulopathien

Erworbene Koagulopathien sind meist Folgen einer verursachenden Grundkrankheit (z. B. Leberinsuffizienz oder Sepsis). Die adäquate Behandlung dieser Grundkrankheit ist in der Regel von langfristig prognosebestimmender Bedeutung. Bei wenigen Koagulopathien, insbesondere bei den Immunkoagulopathien, findet sich aber keine erkennbare Grundkrankheit bei einem relevanten Anteil von Patienten. Die Optimierung der Hämostase mit dem Ziel fatale Blutungskomplikationen oder Thromboembolien zu verhindern, ist in beiden Fällen in der Lage, die Prognose zu verbessern. Meist gelingt dies durch individuell angepasste laborkontrollierte Therapien, die nur schwer einer Überprüfung im Rahmen von Studien zugänglich sind. In den vergangenen Jahren wurde erstmals in plazebokontollierten randomisierten Phase-III-Studien die Bedeutung der therapeutischen Hämostasemodulation zur Mortalitätsreduktion erfolgreich überprüft.

Antiangiogenic strategies in pancreatic cancer

Since the introduction of gemcitabine in the treatment of pancreatic cancer, progress in the use of combination chemotherapies has been very limited. Of the different novel options, antiangiogenic treatment strategies are among those being intensively studied in preclinical and clinical settings of adenocarcinoma of the pancreas. Phase I and limited-size phase II studies using drugs with antiangiogenic properties have reported encouraging results. Overall, the results of phase III studies with some metalloprotease inhibitors and bevacizumab have so far failed to demonstrate a survival benefit for these drugs. Further investigations that will take into account the heterogeneity of pancreatic cancer are warranted using these or other antiangiogenic active substances.

[Coagulation analysis in transplantation patients]

In patients post organ transplantation, the underlying disorder necessitating the transplantation, as well as the transplantation itself, can both mask pre-existing haemostatic abnormalities or lead to them. Since the liver is the main production site for coagulation factors, orthotopic liver transplantation predestinates for acquiring or losing a genetically determined coagulation defect. In coagulation diagnostics, this may lead to a discrepancy between functional plasma tests and molecular biologic findings if these are gathered from nucleated cells of the peripheral blood, as is the standard. Due to the rareness of most defects and the lack of consequences in case of diagnosis of a more common coagulation disorder, no general screening before or after transplantation is required. Underlying diseases leading to liver transplantation as well as the actual transplantation must be considered when interpreting the findings.

Is chemotherapy failure a contraindication for liver resection in liver metastases of colorectal cancer? A multivariate analysis

4066

Background: Liver resection is the only curative treatment offering a chance of long-term survival in patients with colorectal liver metastases. Chemotherapy is increasingly proposed as neoadjuvant treatment in patients with irresectable liver metastases. However, a large number of patients show progress while on chemotherapy. Recent data indicated that liver resection in patients receiving chemotherapy with tumor progress is associated with poor outcome. The aim of the study was to identify risk factors for poor outcome in patients with preoperative chemotherapy with resectable colorectal liver metastases (CRM). Methods: We retrospectively analyzed the outcome of 168 consecutive patients who underwent liver resection for CRM after systemic chemotherapy between 1995 and 2004. Overall, 132 (78.6%) patients had first line, 24 (14.3%) patients second line and 12 (7.2%) third or fourth line chemotherapy. Three groups of patients were identified according to the chemotherapy response. 48 patients (28.6%) had a tumor response (group 1), in 20 (11.9%) the condition stabilized (group 2), and 100 (59.5%) patients had tumor progression (group 3). Median follow-up was 1.8 yrs (range (6 days - 9.5 yrs). Results: Demographic data, size of largest node, number of nodes, extent of resection and postoperative course were equally distributed between groups. Overall, survival was 89%, 56%, and 31% at 1, 3, and 5 years, respectively. Five-year survival was similar between groups. In the univariate analysis, only incomplete resection and vascular invasion were associated with poor outcome. In the multivariate analysis, only vascular invasion was significantly associated with fatal outcome. Neither the number of lines nor the chemotherapeutic agent was associated with decreased survival. Conclusions: In a large patient population, liver resection offered long-term survival for patients with multiple colorectal metastases, even in cases with tumor growth whilst receiving chemotherapy. This underlines that, whenever a curative resection is possible, surgical resection of liver metastases is justified even in patients with therapy failure due to chemotherapy.

No significant financial relationships to disclose.

A randomized second line trial in patients with gemcitabine refractory advanced pancreatic cancer - CONKO 003

4517

Objective: For nearly ten years gemcitabine (G) was standard first line therapy for patients (pts) with advanced pancreatic cancer (APC). There is no consensus about second line therapy after disease progression while receiving G, but 5-FU-based regimens are considered. Results about randomized second line studies in APC are very rare. Our phase II study (ASCO 2002) showed activity of the OFF (oxaliplatin/folinic Acid (FA)/5-fluorouracil (FU) [24h] ) regimen in 23 pts. To examine the impact and the side effects of oxaliplatin we initiated a multicenter phase III study to compare OFF and FF in pts with G refractory APC. Methods: Pts with CT/ MRT confirmed failure with G in first line therapy, Karnofsky Performance Status (KPS) >60%, controlled pain, adequate hematological, renal and liver functions were eligible. Pts were stratified according to duration of first line therapy, KPS and tumor stage. We randomized pts to outpatient treatment with FF (FU 2g/m2 (24h)/ FA 200 mg/m2 (30min) on d1, d8, d15 and d22) or OFF (FF+Oxaliplatin 85mg/m2, d8, d22). In both arms the next cycle started on day 43. Pts were followed with regular staging every 3 months or at any signs of disease progression. Results: Until now we randomized 161 of 165 (planned) pts between 02/2004 and 01/2007. So we expect to present first results (side effects, progression free survival, overall survival) at the meeting.

No significant financial relationships to disclose.

Gerinnungsanalyse bei Transplantationspatienten

Bei Patienten nach Organtransplantation können sich aufgrund der zur Transplantation führenden Grundkrankheit als auch transplantationsbedingt sowohl vorbestehende Hämostasestörungen maskieren als auch entwickeln. Da die Leber den Hauptbildungsort für die Gerinnungsfaktoren darstellt, prädestiniert die orthotope Lebertransplantation für den Erwerb bzw. Verlust eines genetisch determinierten Gerinnungsdefektes. Hier kann es in der Gerinnungsdiagnostik zur Diskrepanz zwischen funktionellen Tests im Plasma und molekularbiologischen Befunden kommen, sofern diese wie üblich aus kernhaltigen Zellen des peripheren Blutes erhoben werden.

Die Seltenheit der meisten Defekte und die fehlenden Konsequenzen bei Nachweis der häufigeren Gerinnungsstörungen führen dazu, dass kein prinzipielles Screening vor oder nach Transplantation gefordert wird. Der Umstand einer zur Transplantation führenden Grundkrankheit ist ebenso wie die Transplantation selbst in die Interpretation von Befunden einzubeziehen.