Final analysis of a multicenter, randomized phase II trial comparing three different chemoradiotherapy regimens in the treatment of patients with locally advanced, nonmetastatic pancreatic cancer

4610

Background: To date, no standard treatment approach for patients (pts) with non-resectable, locally advanced pancreatic cancer (PC) is defined. Methods: Within a prospective phase II trial treatment-naive pts with locally advanced PC and adequate organ function were randomly assigned to three different CRT regimens; all pts received a conventionally fractionated radiotherapy of 50 Gy (with a daily dose of 2.0 Gy) and were randomized to either concurrent 5-FU as a 24h-infusion (350 mg/m2/d on each day of radiotherapy, RT-5FU arm), concurrent low-dose gemcitabine 300 mg/m2 and cisplatin 30 mg/m2 on days 1, 8, 22, and 29 (RT-GC arm), or the same concurrent treatment followed by a sequential chemotherapy with full- dose gemcitabine (1000 mg/m2) and cisplatin (50 mg/m2) every two weeks (RT-GC+GC arm). Treatment duration in the RT- GC+GC arm was upon disease progression or unacceptable toxicity. The primary study endpoint was the overall survival (OS) rate after 9 months (mo); secondary endpoints included response rate (WHO criteria), progression-free survival (PFS), resectability and toxicity. Results: Ninety-five patients (median age 64 years, 54% male, 50% KPS 90–100%) were recruited from 12 German centers. Seventy patients were evaluable for objective response: the intent-to-treat response rate (CR+PR) was 19% in the RT-5FU arm, 22% in the RT-GC arm and 13% in the RT-GC+GC arm, respectively. Overall, 18 pts (19%) underwent surgical resection after initial CRT (R0 in 8 pts). After a median follow-up of 8.6 mo, median PFS was estimated with 4 mo (RT-5FU), 5.6 mo (RT-GC) and 6 mo (RT- GC+GC), respectively (p=0.21). The corresponding median OS times were 9.6 mo, 9.3 mo and 7.3 mo (p=0.61). Hematological grade 3/4 toxicities were higher in the two gemcitabine/cisplatin-containing arms, but no grade 3/4 febrile neutopenia was observed. Regarding non-hematological toxicity, nausea/vomiting were more frequently in the RT-GC and RT-GC+GC arm, whereas diarrhea was more frequent in the RT-5FU arm. Conclusions: Based on these data, gemcitabine/cisplatin-based CRT does not achieve a higher clinical efficacy compared to RT-5FU, and is associated with increased hematological toxicity.

[Table: see text]

Beating of coupled ultraviolet light modes in zinc oxide nanoresonators

Periodic spatial intensity modulations of near-band-gap luminescence light at 3.36 eV photon energy are reported in nanometer-sized resonators of single zinc oxide nanorods. These modulations are observed when the luminescence light, due to excitonic recombination, is excited by a focused low-energy electron beam scanned along the rods. The acceleration energy of only 2 keV allows for a spatial resolution of a few ten nanometers. Numerical calculations based on the theory of dielectric cylindrical waveguides are performed identifying the intensity modulations as beating patterns of coupled TE01 and TM01 modes in the nanoresonator.

Relativistic MeV photoelectrons from the single atom response of argon to a 10 19 W/cm2 laser field

We present photoelectron measurements from argon ionization at 10(19) W/cm(2). Photoelectrons with energies above 400 keV, including a 1.2 MeV cutoff, are in quantitative agreement with a semiclassical, relativistic 3D ionization model that includes a nonparaxial laser field. L-shell photoelectrons have energies and momentum dominated by the field, including the acceleration out of the focus. Yields and angular distributions at 60 keV come from valence shell ionization by strong fields where rescattering and atomic processes determine photoelectron final states.

Amniotic membrane transplantation for persistent corneal epithelial defects in eyes after penetrating keratoplasty

PURPOSE

To determine the primary success and recurrence rate of amniotic membrane transplantation (AMT) for the treatment of persistent corneal epithelial defects (PEDs) in eyes after penetrating keratoplasty (PK).

DESIGN

Retrospective, non-randomized, observational case series.

METHOD

AMT was performed in 24 eyes of 24 patients with erosions (n=6) or ulcers (n=18), which were resistant to medical therapy. All eyes had undergone one (42%) or more PKs before AMT. After the removal of epithelium and pannus (if present), one or more layers of AM ('graft' (n=3), 'patch' (n=5), 'sandwich'=combination of graft/patch (n=16)) were transplanted. Main outcome measures included 'surgical success' (epithelium closed within 4 weeks after AMT), and 'recurrence' (new epithelial defect developing during follow-up after surgical success).

RESULTS

The rate of surgical success was 70% and was found to be inversely proportional to the number of previous PKs. Defects limited only to the centre of the graft had a higher success rate (central: 100%, non-central: 61%). A total of 44% successful eyes (erosions: 75% vs ulcers: 33%) had a recurrence after a mean follow-up of 16+/-13 months. The rate of surgical success was highest (81 vs 67 vs 25%) and the rate of recurrence was lowest (38 vs 90 vs 100%) with the sandwich technique in contrast to the graft or patch techniques used alone.

CONCLUSIONS

AMT may be beneficial in the treatment of PEDs after PK, especially when applying the sandwich technique. Recurrences seem to be more frequent, if PK preceded AMT.

[Radiochemotherapeutic options for bladder cancer]

Radical cystectomy remains the standard of care for muscle-invasive bladder cancer, while for high-risk superficial carcinoma an organ-preserving approach, including transurethral resection (TUR) and intravesical therapy, is recommended. This review summarizes the radiochemotherpeutic options for high risk T1 or muscle-invasive bladder cancer - as an alternative for/or neoadjuvant therapy before radical surgery. Multimodality therapy, including TUR, radiation, and chemotherapy, is associated with recurrence and progression rates of 30 % and 15 %, respectively, in high-risk T1 bladder cancer. For muscle-invasive disease, five-year survival rates in the range of 50 % to 60 % have been published, which is comparable to primary cystectomy series. Approximately 80 % of the surviving patients maintained their own, well functioning bladder. Close coordination among all disciplines is required to achieve optimal results. An integral part of the concept is salvage cystectomy for non-responders or muscle-invasive recurrences. Ideal candidates for the organ-preserving approach are those with early-stage unifocal tumours (T1/T2). Preoperative radiochemotherapy is likely to improve the results of cystectomy alone in patients with locally advanced bladder cancer (T3b, T4).

Radiobiological mechanisms in inflammatory diseases of low-dose radiation therapy

PURPOSE

Whereas X-irradiation with high doses is established to exert pro-inflammatory effects, low-dose radiotherapy (LD-RT) with single fractions below 1.0 Gy and a total dose below 12 Gy is clinically well known to exert anti-inflammatory and analgesic effects on several inflammatory diseases and painful degenerative disorders. Experimental studies to confirm the effectiveness, the empirical dose and fractionation schemes, and the underlying radiobiological mechanisms are still fragmentary.

METHOD

The anti-inflammatory efficiency of LD-RT was confirmed in several experimental in vitro and in vivo models.

RESULTS

In vitro studies revealed a variety of mechanisms related to the anti-inflammatory effect, in particular the modulation of cytokine and adhesion molecule expression on activated endothelial cells and leukocytes, and of nitric oxide (NO) production and oxidative burst in activated macrophages and native granulocytes.

CONCLUSION

Inflammatory diseases are the result of complex and pathologically unbalanced multicellular interactions. It is, therefore, reasonable to assume that further molecular pathways and cellular components contribute to the anti-inflammatory effect of LD-RT. This review discusses data and models revealing aspects of the mechanisms underlying the anti-inflammation induced by low doses of X-irradiation and may serve as a basis for systematic analyses, necessary to optimize LD-RT in clinical practice.

Phase II study of simultaneous radiochemotherapy (RCT) with cisplatin/etoposide followed by consolidation chemotherapy (CT) with platin/gemcitabine for unresectable non-small cell lung cancer (NSCLC)

18103

Background: This phase II study has been conducted to determine the feasibility, toxicity, response rate, local control, distant metastases, and survival of simultaneous RCT (3D conformal radiotherapy with cisplatin/etoposide) followed by consolidation CT with platin/gemcitabine in unresectable NSCLC. Methods: From April 2001 to April 2005, 30 patients with unresectable NSCLC were entered into this trial. All patients had a histological confirmed unresectable non-small cell lung cancer. One patient had stage II, but was functionally unresectable; all other patients had locally advanced NSCLC (IIIA and IIIB). Noncoplanar 3D conformal radiotherapy was given to a total dose of 66.6 Gy (1.4 - 1.8 Gy per day) together with 2 cycles of CT (cisplatin 20 mg/m2 d1–5, d29–33 plus etoposide 90 mg/m2 d1–3, d29- 31). After completion of RCT patients received 4 courses of gemcitabine 900 mg/m2 d1 and d8 with cisplatin 70 mg/m2 d2 (or carboplatin AUC 5 d1) every 21 days. Results: 27 patients went through RCT, 22 patients received consolidation CT. The predominant hematological toxicity was grade 3/4 leukopenia, reported in 33% of patients during the RCT and 36% during the consolidation CT. One patient showed grade 3 radiation pneumonitis during concurrent RCT. No patient died of treatment related toxicity. The response rate was 83% with 2 CR and 23 PR. With a follow up of 24 months median survival was 17.5 months, 2 year survival rate was 40%. We will present median survival and 3 year survival rate with a follow up of 36 months. Conclusions: The simultaneous RCT with cisplatin/etoposide followed by consolidation CT with platin/gemcitabine is feasible and well tolerated. This study should prompt further investigation in a phase III randomized trial.

No significant financial relationships to disclose.

Cetuximab, capecitabine, and oxaliplatin (Cet-CapOx) with concurrent radiotherapy (RT) in advanced rectal cancer (RC): Results of a phase I/II trial

4042

Background: CapOx given concurrently with neoadjuvant RT in rectal cancer is well tolerated and has achieved high rates of pathologic complete response (pCR) in phase II trials. Cetuximab is active in metastatic colorectal cancer. Synergy of cetuximab with RT resulted in improved survival (vs. RT alone) in head and neck cancer. This trial was to evaluate feasibility and efficacy of Cet-CapOx in RT of rectal cancer, with maximal tolerated dose as primary endpoint in phase I, and pCR as primary endpoint in phase II. Method: Patients (pts) had to have untreated, T3–4 and/or N+ disease per MRI or CT plus endoscopic ultrasound, M1 allowed, normal organ function. During conventionally fractionated RT (1.8 Gy for 28 days [d]), cetuximab was given in standard dose (400 mg/m2 on d - 7, then 6 weekly doses of 250 mg/m2, to d35). CapOx was administered as in the phase II trial of our group (Rödel et al, J Clin Oncol 2007), with oxaliplatin (50 mg/m2 d 1,8,22 and 29) plus capecitabine (d1–14 and d22–35) at 3 dose levels: 1,000, 1,300 and 1,650 mg/m2/day. Results: 60 pts were enrolled: Median age 62 [35–83] yrs., male 61%, T3/T4 83/17%, N+ 85%, M1 20%. 7/ 3/ 50 pts. were treated on levels 1/ 2/ 3: as only 1 pt. experienced DLT (diarrhea 4°) on level 1 and none on level 2, level 3 was chosen for phase II (n=50 pts.). Most common toxicity was CTC grade 3 diarrhea in 14% of pts. Full dose of all drugs and of RT was administered in >90% of cycles. No grade 4 toxicity occurred. 53/60 pts underwent resection after completed chemoradiation without increase of perioperative complications when compared to historic controls of CapOx-RT alone. Radiologic downstaging (17 pts. evaluated so far) was seen in 35% for T category and in 67% for N category. Pathologic complete response (45 pts. evaluable) was observed in 9% of pts, another 38% had “good regression” (>50% of tumor cells). Conclusion: CapOx can safely be combined with cetuximab without requiring dose reduction of chemo- or radiotherapy and leads to significant downstaging. However, the relatively low rate of pathologic responses underachieved the assumptions.

[Table: see text]

Thyroid function in paediatric and young adult patients after sarcoma therapy: a report from the Late Effects Surveillance System

OBJECTIVE

The role of chemotherapy in thyroid sequelae after cancer treatment has not been studied systematically, especially in sarcoma patients. The aim of this study was to determine the incidence of post-therapeutic thyroid disorders and their contributing factors in a cohort of paediatric sarcoma patients.

DESIGN

Late effects of sarcoma treatment have been collected prospectively within the Late Effects Surveillance System (LESS) in Germany, Austria and Switzerland since 1998.

PATIENTS

We studied 340 relapse-free paediatric patients (median age at diagnosis 12.2 [interquartile range (IQR) = 7.3-15.6 years] treated for osteosarcoma, soft tissue sarcoma or Ewing's sarcoma within the COSS-96, CWS-96/CWS-2002P or EICESS-92/EURO-E.W.I.N.G.-99 therapy trials. In addition to polychemotherapy, 127 patients were irradiated (mean cumulative dose 47 +/- 9.7 Gy), including 51 patients with irradiation to the head/neck region. Median follow-up was 24.6 (IQR = 11.9-44.9) months.

MEASUREMENTS

We reviewed the results of yearly examinations of serum TSH and fT4 levels and thyroid ultrasound examinations.

RESULTS

The incidence of thyroid disorders was 37% (19/51, 95% CI 24-52%) in patients with head/neck irradiation, and 11% (32/289, 95% CI 8-15%) in patients without irradiation to the head/neck. Thyroid disorders were more frequent in patients treated with idarubicin (P = 0.027) and trofosfamide (P = 0.016). We also found a significant association between raised TSH levels and treatment with trofosfamide (P = 0.008) or idarubicin (P = 0.037) (n = 250).

CONCLUSIONS

The incidence of thyroid disorders in the head/neck-irradiated group was high. Even without head/neck irradiation, we found an increased proportion of patients with thyroid disorders, possibly as a result of chemotherapy.

Hochdosisbrachytherapie des malignen Aderhaut- und Ziliarkörpermelanoms mit 106Ruthenium

BACKGROUND

The purpose of this study was to report the multifactorial results of high-dose (106)Ruthenium plaque brachytherapy for (cilio-)choroidal melanoma and to confirm them by histological examinations.

PATIENTS AND METHODS

100 patients with choroidal or ciliochoroidal melanoma treated by high-dose 106Ruthenium plaque brachytherapy were followed-up for 5 years. 12 secondary enucleated eyes were compared to a non-irradiated matched group by light microscopy.

RESULTS

The 5-year local tumour control rate was 93%, the 5-year survival rate 91%. Late radiogenic side effects occured as a retinopathy in 13%, as an optic neuropathy in 5% and as a secondary glaucoma in 3% of the patients. 14% had to be enucleated, 10% developed metastases. The histopathologic examination revealed significantly higher degrees of necrosis (p=0,041), balloon cell degeneration (p=0,025) and fibrosis (p<0,001) in the irradiated melanomas than in the control tumours.

CONCLUSION

High-dose 106Ruthenium plaque brachytherapy turned out to be an effective treatment procedure for posterior uveal melanoma (not exceeding a prominence of 5,5 mm) with a high rate of local tumour control and a low rate of side effects.

[Clinical significance of gastrooesophageal reflux in asthma]

In clinical practice, gastrooesophageal reflux (GER) and bronchial asthma often coincide. In the case of sufficient asthma control, the asthma does not need to be taken into account when treatment of GER is being evaluated. In patients with symptomatic asthma despite adequate antiasthmatic treatment, a possible causal relationship between GER and the poor responsiveness to asthma therapy has to be considered. An algorithm to guide the diagnostic and therapeutic steps in such cases is presented.

[Combination of asthma and COPD: more frequent as considered to be?]

Evidence-based national and international guidelines are largely aimed to guide in the diagnosis and treatment of asthma or COPD, but none addresses sufficiently mixed disease states of both disorders, which are ill-defined but very common in the daily routine clinic. This is a consensus report of a workshop on mixed disease. Asthma is characterized by a classical clinical history and physical exam, reversible airflow limitation and a high degree of bronchial hyperresponsiveness. In contrast, history (mostly smoker) and findings in typical COPD are different: COPD patients have little if any bronchial hyperresponsiveness and reversibility of the airflow limitation, respectively. However, beyond the full reversible airflow limitation which excludes COPD or mixed disease, none of these criteria are fully discriminatory. Patients with some of the characteristics of both diseases should be classified as mixed disease. A definitive diagnosis however, should only be assigned in a dynamic process. Once diagnosed the patient should be continuously re-evaluated according to the strength of the diagnosis, since the consequent treatment is important: COPD patients with asthmatic phenotype need early inhaled corticosteroids, even if their FEV1 > 50 %. Moreover, allergen avoidance can be indicated. On the other hand, asthma patients with COPD phenotype could benefit from anticholinergics or--if indicated--pulmonary rehabilitation. Mixed disease should be diagnosed as the coexistence of two distinct entities, i. e. asthma (allergic or intrinsic asthma, whichever is appropriate) and COPD.

Nichtinvasives und invasives Harnblasenkarzinom

Therapy of superficial bladder tumors is transurethral resection (TUR), and in cases of pT1 or high-grade tumors a re-TUR is indicated. Patients with carcinoma in situ receive intravesical chemotherapy or BCG for at least 3 months. Persistent carcinoma in situ may be treated by radical cystectomy. With the provision of a functionally adequate urinary diversion, cystectomy represents an effective treatment for patients with muscle-invasive bladder cancer without metastatic spread. Regional lymph node metastases can be found in up to 15% of stage T1 disease and are present in 33% of stage T3/4 lesions. Thus, lymphadenectomy gains diagnostic and possibly also therapeutic importance. For selected patients, who cannot be treated by radical cystectomy, multimodal concepts aiming to preserve the bladder are discussed. After or prior to cystectomy systemic chemotherapy may become necessary for some patients to positively affect the course of the disease in cases of locally advanced or metastatic lesions.

Postoperative concurrent radiochemotherapy versus radiotherapy in high-risk SCCA of the head and neck: Results of the German phase III trial ARO 96–3

5507

Background: Despite resection and postoperative irradiation high-risk (3 or more involved lymph nodes, extra-capsular disease and/or microscopically involved mucosal margins of resection) squamous cell carcinomas (SCCAs) of the head and neck frequently recur in the tumor bed. Postoperatively radiochemotherapy (RCT) with cis-Platin (CDDP)/5-FU versus radiotherapy (RT) alone was compared in a randomized trial. Methods: Between 5/97 and 12/04, 440 patients who had high-risk SCCAs of the head and neck were enrolled in this prospectively randomized phase III trial. Following resection and neck dissection, 214 patients were randomly assigned to RT (66 Gy/33 Fx/6.6 weeks) and 226 patients to identical RT plus CDDP (20 mg/m2 on day 1–5, 29–33) and 5-FU (600 mg/m2 on day 1–5, 29–33). Results: The 5 year local-regional control rate is 72.2 ± 3.7% following RT and 88.6 ± 2.4% for the RCT group (p = 0.00259; 5-year progression free survival 50.1 ± 4.0% and 62.4 ± 4.4% (p = 0.024) and 5-year overall survival 48.6 ± 4.4% vs. 58.1 ± 4.6% (p = 0.11). There was no difference in the 5 year incidence of distant metastases (19.3 ± 3.6% vs 25.5 ± 4.6%; p = 0.45). The incidence of grade 3+ acute toxicity was higher during RCT: mucositis 12.6% vs. 20.8% (p = 0.04), leucopenia 0% vs. 4.4% (p = 0.007). Conclusions: Acute toxicity is increased to an acceptable level by RCT. Postoperative RCT compared to RT improves locoregional control and progression free survival; thus survival as a trend is improved by 10% after 5 years. Supported by Deutsche Krebshilfe 70–2140.

No significant financial relationships to disclose.

Phase I/II study of cetuximab, capecitabine and oxaliplatin (CAPOX) combined with standard radiotherapy (RTX) as neoadjuvant treatment of advanced rectal cancer (RC)

3574

Background: CAPOX given concurrently to neoadjuvant RTX in RC is well tolerated and yielded high rates of pathologic complete responses in phase II trials. Cetuximab, a monoclonal antibody targeted against the EGF receptor, is active in metastatic colorectal cancer. Furthermore, synergy of cetuximab with RTX was shown in improved survival vs. RTX alone in head and neck cancer. This trial was to evaluate maximal tolerated dose (MTD), feasibility and efficacy of CAPOX + RTX with cetuximab in RC. Method: Patients (pts) had to have unpretreated T3–4 and/or N+ disease, with distant metastases allowed. During a conventionally fractionated RTX (1.8 Gy for 28 days [d]), cetuximab was given in standard dosage (400mg/m2 on d-7, then 6 weekly doses of 250 mg/m2, to d35). CAPOX was given on the basis of a previously examined schedule with oxaliplatin (50 mg/m2 d 1,8,22 and 29) in combination with capecitabine (d1–14 and d22–35) at 3 dose levels: 1000, 1300 and 1650mg/m2 bid. In phase I, a standard 3+3 design was used, allowing for dose escalation in 0/3 or 1/6 pt with dose-limiting toxicity (DLT). Results: 13 pts were enrolled: Median age 58 [35–75] yrs., m/f 7/6 pts. T3 85%, T4 15%; N+ 92%, M1 46%; G2 92%, G3 8%. As on dose level 1 one DLT (diarrhea grade 3) occurred, it was extended to 7 pts. No further DLT was observed as it was on levels 2 and 3 with 3 pts each. Full RTX course was administered in all pts, while CAPOX-cetuximab was stopped in the DLT case and cetuximab in 1 pt with hypersensitivity reaction. Toxicities are displayed in the table . Conclusion: CAPOX can safely be combined with cetuximab without requiring chemotherapy dose reduction. The multicenter phase II part of the trial with 31 pts. included so far is ongoing and updated results (including resectability) will be presented.

[Table: see text]

[Table: see text]

Randomized phase II trial comparing gemcitabine/cisplatin-based chemoradiotherapy (CRT) to 5-FU-based CRT in patients with locally advanced pancreatic cancer

4038

Background: CRT is a relevant treatment option for patients with unresectable pancreatic cancer. Up to now, 5-FU has been the drug of choice for concurrent CRT. Based on evidence that also gemcitabine may improve the antitumor activity of radiation, a randomized phase II trial was undertaken. Methods: Patients with locally advanced, non-metastatic and histologically proven pancreatic cancer were included into a three-arm trial. In arm treatment arm A, radiation (CTV I up to 50.0 Gy, conventional fractionation) was applied concurrently with protracted venous infusion of 5-FU (350 mg/m2/irradiation day). In treatment arm B, patients received radiotherapy together with gemcitabine (300 mg/m2/d 30 minute infusion) and cisplatin (30 mg/m2/d 60 minute infusion) applied on days 1, 8, 22, and 29. In treatment arm C, patients received an identical regimen of CRT as described for arm B which was followed by 4 cycles of chemotherapy with gemcitabine (1000mg/m2, 30 min iv) plus cisplatin (50mg/m2) applied at 2-week intervals. Patients were stratified for Karnofsky performance status (KPS ≥80% vs. <80%). The primary end-point of the trial was the 9-months survival rate. Results: Ninety-six patients with a median age of 63.5 years (range 40–75 years) were included into the trial from 01/02 until 06/05 (arm A: 32 patients, arm B: 33 patients, arm C: 31 patients). Two patients did not complete CRT. At the time of evaluation, 66 patients (70.2%) had died. 9-months survival rate was 60%, 58%, and 46% in treatment arms A, B, and C, respectively. Median overall survival in arm A was 9.6 mo (95% CI, 8.7–10.5 mo), in arm B 9.6 mo (95%CI, 7.4–11.8 mo), and in arm C 6.1 mo (95% CI, 1.6–10 mo). Secondary end-points such as treatment-related toxicity, response rate, secondary resectability, and time to progression are under evaluation. Conclusions: CRT with gemcitabine plus cisplatin is not superior to 5-FU-based CRT with regard to the primary end-point of 9-months survival rate. Updated results will be presented at the meeting.

No significant financial relationships to disclose.