Cervical squamous cell carcinoma of the esophagus-a unique series of limited resection and free jejunal graft interposition after neoadjuvant RCTx in 94 patients

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Background: The treatment of cervical squamous cell carcinoma (SCC) is discussed controversial. A limited resection of the cervical esophagus and reconstruction with a free jejenunal graft interposition using a microsurgical technique has been evaluated in our department. Methods: From 1986–2006 94 patients with the initial staging uT2–4, N any cM0 (75 male, 19 female; age 56+9.6, range: 19–74 years) with cervical SCC of the esophagus were treated with limited esophageal resection and reconstructed with a free jejunal autograft in combination after neoadjuvant RCTx within phase II studies. The median follow up is 23 months (0.1–120). Results: Laryngectomie had to be performed in 13 patients (14%). Recurrent nerve palsy on one side was found in 15/77 (19.5%) and on both sides in 13/77 (17%). Complications occurred in 70 (75%) of the patients, 47% of the patients had more than one complication. Reoperations were necessary in 29 patients (31%). The 30-day mortality was 2/94 (2.1%). Median survival is 29.9 months (1-, 3 and 5-year survival rates: 81%, 43%, 41%). 27/94 (29%) patients showed complete tumor regression (ypT0) after RCTx. Prognostic factors are complete tumor regression (p=0.007), ypT-(p=0.006), the R-category (p=0.018), but not the ypN-category (p=0.06). Neither the occurrence of complications (p=0.57) nor reoperation (p=.89) are associated with survival. The complete resection rate was 76 % (71/94). Median survival is 34.3 months, median recurrence free survival is 21.4 months for the R0 resected patients. 30/71 (42%) had a recurrence (locoregional in 27% (19/71), distant metastases in 10% (7/71) and a combination of both in 6% (4/71). Conclusions: Limited resection of the esophagus and reconstruction by a free jejunal graft after neoadjuvant RCTx is highly sophisticated and complex. Despite a high complication and reoperation rate the results are excellent with a low mortality and a good prognosis. This approach seems to be appropriate for cervical SCC in oncological centers with an infrastructure providing interdisciplinary management. Comparable data for cervical SCC of the esophagus without the inclusion of hypopharyx carcinoma do not exist in literature so far.

No significant financial relationships to disclose.

Squamous cell carcinoma and Zenker diverticulum

Squamous cell carcinoma in a Zenker diverticulum is a very rare condition. We report a case of a patient with a Zenker carcinoma, who was primarily functionally inoperable and therefore received neoadjuvant radiochemotherapy before cardiac bypass surgery. After a complicated course with cardiogenic shock and myocardial infarction, a re-evaluation of functional risk analysis and the tumor situation revealed operability. Subsequently, partial hypopharyngectomy and partial cervical esophageal resection with lymphadenectomy was performed. Reconstruction of the gastrointestinal continuity was made by interposition of a free small bowel graft and microvascular anastomosis. The postoperative course showed a small anastomotic leakage of the hypopharyngeal-small bowel anastomosis, which was successfully treated conservatively.

Intercellular adhesion molecule-1: a consistent inflammatory marker of the cutaneous radiation reaction both in vitro and in vivo

BACKGROUND

Radiation damage to skin is a key diagnostic and prognostic parameter for patients accidentally exposed to radiation. Moreover, skin is a target organ for crucial side-effects of routine radiotherapy. The pathophysiology of the cutaneous radiation reaction is in many respects still unknown. The acute inflammatory radiation reaction of skin has been shown to involve alterations in cell-cell and cell-matrix interactions, which are mediated by cellular adhesion molecules.

OBJECTIVES

To evaluate the effect of ionizing radiation on intercellular adhesion molecule-1 (ICAM-1) expression in human skin cells.

METHODS

Dermal monolayer cells, a three-dimensional skin model and skin biopsies were investigated for ICAM-1 expression after ionizing radiation using flow cytometry, quantitative reverse transcription-polymerase chain reaction and immunohistochemistry. ICAM-1 expression in monolayer cells pretreated with protein kinase inhibitors and dexamethasone prior to irradiation was analysed by flow cytometry.

RESULTS

Using different sources of skin cells, we demonstrated a consistent upregulation of both ICAM-1 mRNA and protein expression by ionizing radiation. Blocking experiments revealed that tumour necrosis factor-alpha, another ICAM-1 inducer, does not account for the effect of radiation. Radiation-induced upregulation of ICAM-1 expression was significantly attenuated by inhibitors to protein kinase C, mitogen-activated protein (MAP) ERK kinase, p38 MAP kinase and phosphatidylinositol 3-kinase. The anti-inflammatory agent dexamethasone suppressed the effect of radiation on ICAM-1 expression, suggesting its usefulness to treat the cutaneous radiation reaction.

CONCLUSIONS

Our data suggest that ICAM-1 is a consistent inflammatory parameter of the cutaneous radiation reaction both in vitro and in vivo that might provide new therapeutic options for diagnosis and treatment of effects of radiation.

Survival improvement by systemic chemotherapy in adult patients with recurrent glioblastoma multiforme treated with two courses of radiotherapy

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Background: We evaluated the added value of systemic chemotherapy (CTx) in adult patients with recurrent supratentorial glioblastoma multiforme (GBM) selected to receive local re-treatment (administered as a 2nd course of radiotherapy, RTx). Methods: Retrospective comparison of two patient cohorts treated subsequently during different time periods. All patients had histologically confirmed recurrent GBM. Minimum recurrence-free interval was 4 months. The first cohort (n=26) had surgical resection and standard postoperative external beam RTx followed by a second course of external beam RTx for recurrence (median cumulative dose 102 Gy). None of these patients ever received CTx during the whole course of disease. The more recently treated cohort (after 1999) of 19 patients also had surgical resection and 2 courses of external beam RTx (median cumulative dose 90 Gy). After primary local treatment, 9 of these patients had adjuvant nitrosourea-based CTx. At recurrence, all 19 patients received temozolomide 150–200 mg/m2/day for five days every 4 weeks in addition to RTx. Results: The cohort without CTx had less favorable baseline characteristics, because of their significantly lower median KPS at recurrence (70 vs. 90%, p<0.01) and shorter interval between primary diagnosis and recurrence (12 vs. 16 months, p<0.05). However, these patients were non-significantly younger (median age 44 vs. 50 years, p>0.05). The percentage of patients with secondary GBM was similar (21 vs. 23%, p>0.5). Median survival from re-irradiation was significantly better in the RTx plus CTx group, 9 vs. 5 months (p<0.05). In multivariate analysis, prognosis was significantly improved by CTx. Importantly, there was also an advantage when overall survival from first diagnosis was evaluated, median 24 vs. 19 months (p<0.05). Conclusion: The current data suggest that re-irradiation plus temozolomide is better than re-irradiation alone. CTx led to a prolongation of overall survival from first diagnosis by 5 months. The most intensively treated, prognostically favourable de-novo GBM patients had surgical resection, 2 courses of RTx and 2 different systemic CTx regimens.

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Possible individualized therapy by early assessment of response during neoadjuvant radiochemotherapy in esophageal squamous cell carcinoma patients by 18-FDG-PET

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Background: Response evaluation by positron emission tomography with the glucose analog [18F]-fluorodeoxyglucose (FDG-PET) has been used in patients with esophageal squamous cell carcinoma (ESCC) after neoadjuvant radiochemotherapy (RTx/CTx). This prospective study was undertaken to compare FDG-PET assessment of tumor response during RTx/CTx with histopathology in patients with ESCC, and to correlate the findings with survival. Methods: Patients (n=61) with histologically proven intrathoracic ESCC (cT3, cN0/+, cM0) underwent preoperative, simultaneous RTx/CTx followed by esophagectomy between 1996 and 2005. The patients underwent FDG-PET prior to and 2 weeks after the begin of RTx/CTx (20Gray). Histopathological response was quantified as the percentage of residual tumor cells. The threshold pre-therapy-to-during-therapy decrease in standardized uptake value by FDG-PET used to define metabolic responders (ΔSUVR) was -30%. Results: Receiving-operator-curve analysis (ROC) for determination of metabolic response revealed an area-under-curve (AUC) of 7140 (p=0.005) with a sensitivity of 76%, specificity (70%), a positive predictive value of 81% and a negative predictive value of 64% (p<0.0001). Responder by FDG-PET during the neoadjuvant treatment (p=0.016) as well as Histopathology (p<0.0001) showed substantially better survival compared to nonresponders. Conclusions: Changes in tumor metabolic activity by FDG-PET during neoadjuvant RTx/CTx allows an accurate determination of response due to the multimodal approach in patients with ESCC. This stratification may lead to a change of the neoadjuvant into a definitive therapy concept in nonresponders (individualized tumor therapy).

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Sequential and/or concurrent hypofractionated radiotherapy and concurrent chemotherapy in neoadjuvant treatment of advanced adenocarcinoma of the pancreas. Outcome and patterns of failure

BACKGROUND/AIMS

To investigate treatment outcome and patterns of failure of sequential chemotherapy (CHT) and/or concurrent hypofractionated radiotherapy (RT) and CHT followed by surgery in locally advanced non-metastatic pancreatic adenocarcinoma.

METHODOLOGY

Seven patients with locally advanced but marginal resectable tumors (close contact but no signs of infiltration of the mesenteric vessels and/or vena portae) were treated with hypofractionated RT (5x3 Gy per week) and concurrent continuous infusion (300 mg/sqm/24 h, 7 days per week) of 5-fluorouracil (FU). Ten patients with locally advanced disease with radiologically suspected infiltration of the mesenteric vessels and/or v. portae were treated with 2 cycles of Cisplatin (75 mg/sqm) and Gemcitabine (2x1250 mg/sqm), and patients without tumor progression received the same concurrent RT/CHT as group 1. Four weeks after RT/CHT radical pancreatectomy was planned for patients with stable disease or remission.

RESULTS

Toxicity was low in both groups, with no CTC grade 4 toxicity. In group 1, RT/CHT was completed in all patients. There was no radiological remission, but stable disease in 5 out of 7 patients. All 5 patients underwent resection of the primary tumor with a R0-resection in 3 patients. In group 2, 8 patients completed CHT and RT/CHT treatment as planned. There were 3 with partial remission. Operation was done in 4 patients, but only one R0 resection was achieved. The median survival time for all 17 patients is 13 months, with 1- and 2-year survival being 53% and 18%, respectively. Local progression was observed in 9, peritoneal seeding in 7 and distant metastasis (mostly liver and lung) in 8 patients.

CONCLUSIONS

The neoadjuvant therapy could be administered with low toxicity. Results of this study warrant further investigation aiming at optimal tailoring in of this treatment approach in these two subgroups of patients.