Cytoreduction and hyperthermic intraperitoneal chemotherapy (CS/HIPEC) in colorectal cancer: Evidence-based review of patient selection and treatment algorithms

Cytoreduction and heated intraperitoneal chemotherapy (CS/HIPEC) is increasingly utilized as a treatment strategy for patients with peritoneal metastases from various primary tumor sites. For this heterogenous procedure, related to patient characteristics, patient selection, and the extent of surgical completeness of cytoreduction, high level evidence (ex: multiple randomized controlled trials) is not available to support efficacy. This review of the available literature supporting application of the procedure, focusing on colorectal cancer, provides a summary of current evidence for patient selection and treatment algorithms based on patient presentation.

Recurrent Hypertriglyceridemic Pancreatitis (HTGP); and the Use of Insulin Drip as Treatment

INTRODUCTION

Chronic pancreatitis by definition is a recurrent episode of acute pancreatitis and is commonly associated with alcoholism in the US. Another cause of chronic pancreatitis is hypertriglyceridemia (HTGP);, occurring in 1-5 percent of cases. The incidence of HTGP is higher in patients with diabetes and HIV, usually requiring triglyceride levels > 1000 mg/dL.

CASE

A 33 year old man with uncontrolled type 1 diabetes and recurrent pancreatitis, first diagnosed 5 years prior, presented as a transfer from an outside hospital for a recurrent episode of HTGP. He reported recurrent pain episodes, requiring 6-9 hospitalizations within the last year for pancreatitis. He reported poor compliance with his insulin regiment at home. Other home medications included gemfibrozil, lisinopril, niacin, and omega-3 fatty acid. On transfer, his glucose was 296, triglyceride level was >3600, and A1C of 12.4. Transfer report lab work showed a triglyceride level >7000 and a lipase of 600. The patient had severe, diffuse abdominal tenderness on examination. He was diagnosed with pancreatitis secondary to hypertriglyceridemia due to a lipoprotein metabolism disorder and long-standing uncontrolled DM1. An intensive insulin drip was started on this patient, with goals of correcting his TG to less than 500 along with lowering his glucose. After 13 days, mostly on insulin drip, his TG decreased to 995 and pain was controlled, eventually tolerating a diabetic diet. He was encouraged to modify his diet and take his medications as directed at discharge.

DISCUSSION

The relationship between hypertriglyceridemia and pancreatitis is poorly understood. In HTGP, a decrease in triglyceride concentration is a management priority. Rapid triglyceride concentration lowering is managed by insulin or plasmapheresis. As HTGP often presents in patient with uncontrolled diabetes, insulin is frequently used as treatment to lower both blood glucose and triglycerides; insulin decreases serum triglyceride levels by enhancing lipoprotein lipase activity and inhibiting hormone sensitive lipase, accelerating metabolism and decreasing adipocyte breakdown. Patients should be educated on the importance of compliance with drug therapy and lifestyle modifications.

Abstract P6-09-39: The role of quantitative estrogen receptor status in predicting breast tumor response to neoadjuvant chemotherapy

Introduction:

Patients with Estrogen Receptor negative breast cancer (BC) are known to have higher tumor response rates than ER positive patients when treated with neoadjuvant chemotherapy (NCT). Few studies have assessed ER status as a quantitative continuous measure in predicting tumor response in this setting.

We aimed to study the association between quantitative ER status and tumor response at surgery in BC patients treated with NCT at our institution, and identify potential predictors of better survival outcomes.

Methods:

A retrospective review using a neoadjuvant BC database (The "Sunnybrook Biomatrix") identified 304 eligible patients that were included in the analyses. A univariate followed by a multivariable logistic regression analyses were conducted to assess the association between quantitative ER (expressed in percentage) and tumor response (good vs. poor response defined as < vs. ≥ 50% reduction in tumor size) while controlling for potential confounders.

For the secondary outcome, the Kaplan Meier method was used to estimate the recurrence free survival (RFS) in this cohort. Predictors of RFS were identified using a cox proportional hazards model (CPH) to adjust for clinically relevant variables. A log-rank test was used to compare RFS between groups for any significant binary predictor.

Results:

The median follow up of all patients was 43.3 months (Q1-Q3: 28.7-61.1). Quantitative ER was inversely associated with tumor response in a multivariable logistic regression model (Odds Ratio 0.99 95%CI: 0.99-1.00, p=0.027). A cut-off of 60% seemed to best predict the association based on the c-statistic (c=0.67) and the receiver operating characteristic curve.

However, quantitative ER was not associated with RFS; pathologic complete response (pCR) was shown to be an independent predictor of RFS in a CPH model (Hazard Ratio: 0.17, 95% CI: 0.07, 0.43, p=0.0002) in all patients, after controlling for potential confounders. At 5 years, 93% of patients with pCR and 72% of patients with residual tumor (no pCR) were recurrent-free respectively (log-rank test p=0.0012).

Conclusion:

This study suggests that BC patients with ER status < 60% are more likely to respond to NCT. Although ER status itself did not predict for relapse-free survival, patients with a pCR had better RFS, and this association was seen amongst all tumor phenotypes.

The role of quantitative ER in predicting and maximizing tumour response to NCT (including optimizing pCR rate) needs to be better defined in prospective studies.

Key words: Estrogen receptors, breast cancer, quantitative, tumor response, pathologic complete response.

Citation Format: Raphael J, Trudeau M, Paramsothy T, Lee N, Gandhi S. The role of quantitative estrogen receptor status in predicting breast tumor response to neoadjuvant chemotherapy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-09-39.

Managing Stigma: Women Drug Users and Recovery Services

Women who use drugs are stigmatized for their drug use behavior, which marginalizes them from mainstream society. Stigmatization can be viewed as an attempt by social services to exert control. Research shows that these strategies do not work well for discouraging drug use; whereas attempts to reduce the stigma related to drug use can encourage users to stop use. Using qualitative methods and grounded theory analysis, the goal of this study is to examine (1) the stigmatization of drug use through different stages; (2) how stigmatized women drug users perceive normality; and (3) barriers and challenges to recovery. Based on in-depth interviews from 20 women who used methamphetamine, the analysis focuses on stigmatization before the initiation of drug use, difficulties related to stigma as drug users, and challenges due to stigmatization as they recover from drug use. Findings show that women are stigmatized before they use drugs, face more stigma as they use, and even during recovery society still holds onto the label of former drug user, making it difficult to avoid stigma. The findings contribute to a better understanding of how stigmatization of women drug users impacts their recovery and provides suggestions for social service and treatment providers.