Colorectal peritoneal carcinomatosis treated by completed surgery and systemic chemotherapy without HIPEC

e14017

Background: Cytoreductive peritoneal surgery (CPS) associated with hyperthermic peritoneal chemotherapy (HIPEC) has become the standard treatment for peritoneal carcinomatosis (PC) of colorectal origins. Nevertheless, if CPS efficacy is demonstrated, evidence supporting HIPEC role is lacking. Methods: Overall survival (OS), progression-free survival (PFS) and outcomes were analysed retrospectively for thirty consecutively included patients treated for colorectal PC with CPS and systemic chemotherapy only. Outcomes and morbidity of the treatment were compared to outcomes and morbidity in the literature following CPS + HIPEC treatments. Results: PCI indices ranged from 1-21 with a mean of 9. Median hospitalization duration was 15 days (range 5-51), and median intensive care unit stay was 1 day (range 0-7). There was no post-operative mortality. Seventeen complications were Grade 1 or 2 (Dindo & Clavien), and remaining 13 were Grade 3. Median follow up was 40.7 [95%CI: 15.1 – 66.3] months. Median OS was 30.7 months [95%CI: 12.65-48.66}]. OS estimates were 83% [95CI%: 63.9- 92.5] and 45% [95%CI: 23.7-64.4] at 1 year and 3 years respectively. Median PFS was 11.1 months [95%CI: 7.98-14.25]. PFS at one year was 43.2% [95%CI: 24.7-60.4]. Patients without any other metastases (n=17) had a median OS of 73.3 months [95%CI: 25.7-120.9], compared with median OS of 18.7 months [95%CI, 16.9-20.6] for patients with at least one liver or lung metastases (p=0.011). Conclusions: The results obtained for patients with colorectal PC treated by CPS and systemic chemotherapy compare favourably with series including HIPEC in the treatment. No mortality, shorter operation duration and hospitalization, less blood loss and transfusions, and no hematologic toxicity were observed.

Absence of transcriptomic signature of response to chemotherapy in metastatic colorectal carcinoma patients

Aim: Tumor gene-expression profiling may define signatures capable of discriminating between responders and nonresponders to chemotherapy. Patients & methods: Fifty seven metastatic colorectal cancer patients were prospectively included and 40 tumors were analyzed. Patients were treated in first line with 5-fluorouracil associated with irinotecan or oxaliplatin. Response was evaluated using WHO criteria every 2 months after chemotherapy. Gene-expression profiling was performed using Applied Biosystems microarrays (Human Genome Survey Microarray v2.0; Paris, France). Data were analyzed using Bioconductor packages. Differential-expression analysis was performed by fitting a linear model. Moderated t-statistics were computed and p-values were adjusted for false-discovery rate. Pearson correlations tests were evaluated between gene expression and progression-free and overall survival. Results: Nonsupervised analysis did not show any clustering of expression levels according to treatment response. Supervised analysis compared expression levels between responders and nonresponders, within each treatment group and independently from treatment. No genes were identified as differentially expressed at a p-value of 10-3 and false-discovery rate of 30%. No correlation between expression levels and survival data was found. Conclusion: These negative results show that the determinants of response to chemotherapy should be sought not only in the tumor characteristics, but also among the processes leading to drug availability to the tumor.

Original submitted 7 July 2011; Revision submitted 17 October 2011

Unresectable colorectal cancer liver metastases treated by intraoperative radiofrequency ablation with or without resection19

Background

Despite neoadjuvant chemotherapy, few patients with colorectal cancer liver metastases (CRLM) are eligible for liver resection. The aim of the present study was to investigate the efficacy of intraoperative radiofrequency ablation (IRFA) in the treatment of unresectable CRLM.

Methods

Patients with unresectable metastases confined to the liver were eligible for this prospective, multicentre phase II study conducted between 2003 and 2008. They received IRFA treatment either with or without parenchymal resection, and underwent clinical and pathological examinations. The primary endpoint was complete hepatic response at 3 months. Overall, event-free and local progression-free survival, morbidity and quality of life were also examined.

Results

Fifty-two patients were included, all of whom received neoadjuvant chemotherapy. They had a median of 5 (range 1–13) metastases, mostly bilateral or recurrent. A complete hepatic response was observed in 39 patients (75 (95 per cent confidence interval (c.i.) 61 to 86) per cent). Of ten patients with hepatic recurrence at 3 months, two relapses were at the site of ablation. Median follow-up was 2·9 (95 per cent c.i. 2·5 to 3·6) years. The 1-year local progression-free survival rate was 46 (95 per cent c.i. 32 to 59) per cent, the 3-year event-free survival rate was 10 (95 per cent c.i. 4 to 21) per cent and the 5-year overall survival rate was 43 (95 per cent c.i. 21 to 64) per cent. Twenty patients had postoperative complications, including one death. Quality of life increased over time for patients without disease progression.

Conclusion

IRFA, either with or without resection, is a promising treatment option for patients with unresectable CRLM. Registration number: NTC00210106 (http://www.clinicaltrials.gov).

Higher harmonic anisotropic flow measurements of charged particles in Pb-Pb collisions at sqrt(s(NN)) = 2.76 TeV

We report on the first measurement of the triangular v3, quadrangular v4, and pentagonal v5 charged particle flow in Pb-Pb collisions at sqrt(s(NN)) = 2.76  TeV measured with the ALICE detector at the CERN Large Hadron Collider. We show that the triangular flow can be described in terms of the initial spatial anisotropy and its fluctuations, which provides strong constraints on its origin. In the most central events, where the elliptic flow v2 and v3 have similar magnitude, a double peaked structure in the two-particle azimuthal correlations is observed, which is often interpreted as a Mach cone response to fast partons. We show that this structure can be naturally explained from the measured anisotropic flow Fourier coefficients.

Centrality dependence of the charged-particle multiplicity density at midrapidity in Pb-Pb collisions at sqrt[s(NN)] = 2.76 TeV

The centrality dependence of the charged-particle multiplicity density at midrapidity in Pb-Pb collisions at sqrt[s_{NN}]=2.76  TeV is presented. The charged-particle density normalized per participating nucleon pair increases by about a factor of 2 from peripheral (70%-80%) to central (0%-5%) collisions. The centrality dependence is found to be similar to that observed at lower collision energies. The data are compared with models based on different mechanisms for particle production in nuclear collisions.

Complications of intraoperative radiofrequency ablation of liver metastases

BACKGROUND

Intraoperative radiofrequency ablation (IRFA) of liver metastases can be used to treat patients with complex tumours that are unsuitable for parenchymal resection alone. This systematic review assesses the frequency, patterns and severity of complications associated with this procedure.

METHODS

We carried out a bibliographic search on MEDLINE focused on IRFA for liver metastases, excluding hepatocarcinomas, and on intraoperative use, excluding percutaneous application.

RESULTS

Thirty papers published between 1999 and 2007 were analysed. They covered a total of 2822 patients and 1755 IRFA procedures. The indications and techniques for IRFA differ from those for percutaneous treatment, as do associated results and complications. Specific complications associated with IRFA, such as liver abscesses, biliary stenoses and vascular thromboses, are directly correlated with the indications and associated procedures. Published results should be interpreted with caution as IRFA can be used alone or combined with parenchymal resection.

CONCLUSIONS

Specific complications related to IRFA are rare, especially for lesions of <35 mm in size located far from a main biliary duct, when additional septic procedures are not used. A lesion-by-lesion approach based on the benefit : risk ratio should therefore be used in the process of making surgical decisions. Combining resection with IRFA leads to higher morbidity, especially in difficult patients with numerous bilateral lesions, but may be necessary to achieve R0 (microscopically negative margins) outcomes.

Elliptic flow of charged particles in Pb-Pb collisions at sqrt[S(NN)] = 2.76 TeV

We report the first measurement of charged particle elliptic flow in Pb-Pb collisions at sqrt[S(NN)] =2.76 TeV with the ALICE detector at the CERN Large Hadron Collider. The measurement is performed in the central pseudorapidity region (|η|<0.8) and transverse momentum range 0.2<p t<5.0 GeV/c. The elliptic flow signal v₂, measured using the 4-particle correlation method, averaged over transverse momentum and pseudorapidity is 0.087 ± 0.002(stat) ± 0.003(syst) in the 40%-50% centrality class. The differential elliptic flow v₂ p t reaches a maximum of 0.2 near p t =3 GeV/c. Compared to RHIC Au-Au collisions at sqrt[S(NN)] 200 GeV, the elliptic flow increases by about 30%. Some hydrodynamic model predictions which include viscous corrections are in agreement with the observed increase.

Charged-particle multiplicity density at midrapidity in central Pb-Pb collisions at sqrt[S(NN)] = 2.76 TeV

The first measurement of the charged-particle multiplicity density at midrapidity in Pb-Pb collisions at a center-of-mass energy per nucleon pair √ S NN = 2.76 TeV is presented. For an event sample corresponding to the most central 5% of the hadronic cross section, the pseudorapidity density of primary charged particles at midrapidity is 1584 ± 4(stat) ± 76(syst), which corresponds to 8.3 ± 0.4(syst) per participating nucleon pair. This represents an increase of about a factor 1.9 relative to pp collisions at similar collision energies, and about a factor 2.2 to central Au-Au collisions at √ S NN = 2.76 TeV. This measurement provides the first experimental constraint for models of nucleus-nucleus collisions at LHC energies.

Midrapidity antiproton-to-proton ratio in pp collisons at sqrt[s]=0.9 and 7 TeV measured by the ALICE experiment

The ratio of the yields of antiprotons to protons in pp collisions has been measured by the ALICE experiment at sqrt[s]=0.9 and 7 TeV during the initial running periods of the Large Hadron Collider. The measurement covers the transverse momentum interval 0.45<p_{t}<1.05  GeV/c and rapidity |y|<0.5. The ratio is measured to be R_{|y|<0.5}=0.957±0.006(stat)±0.014(syst) at 0.9 TeV and R_{|y|<0.5}=0.991±0.005(stat)±0.014(syst) at 7 TeV and it is independent of both rapidity and transverse momentum. The results are consistent with the conventional model of baryon-number transport and set stringent limits on any additional contributions to baryon-number transfer over very large rapidity intervals in pp collisions.

Covered stents are better than uncovered stents for transjugular intrahepatic portosystemic shunts in cirrhotic patients with refractory ascites: a retrospective cohort study

BACKGROUND AND STUDY AIMS

Transjugular intrahepatic portosystemic shunt (TIPS) is an accepted interventional technique to treat refractory ascites in cirrhotic patients with severe portal hypertension. The expanded-polytetrafluoroethylene (e-PTFE) covered stent-graft (cs-TIPS) gives a better shunt patency rate than uncovered stents (ncs-TIPS). Our aim was to retrospectively evaluate whether cs-TIPS indeed improves refractory ascites and overall survival in a more effective way than ncs-TIPS in patients with cirrhosis.

PATIENTS AND METHODS

From 1992 to 2006, 222 cirrhotic patients with refractory ascites underwent a TIPS-procedure. In 126 patients a ncs-TIPS was inserted, in the remaining 96 patients a csTIPS was inserted. Liver transplantation and/or death were the end points of the follow-up.

RESULTS

The baseline characteristics of both groups were similar: age (55 +/- 11 years, ncs-TIPS/56 +/- 10 years, cs-TIPS), alcoholic cirrhosis (73% ncs-TIPS/80% cs-TIPS), Child-Pugh (9 +/- 2.0 ncs-TIPS/9.2 +/- 1.3 cs-TIPS) and MELD (15 +/- 6 ncs-TIPS/15 +/- 4.9 cs-TIPS), except that the bilirubin level was higher in the cs-TIPS group (2.5 +/- 2.7 mg/dL in cs-TIPS vs. 1.5 +/- 3.6 mg/dL in ncs-TIPS). One year shunt dysfunction occurred in 49% (n=63) of the ncs-TIPS vs. 19% (n = 18) of the cs-TIPS (P < 0.0001) and post TIPS encephalopathy in 56% (n=70) of the ncs-TIPS vs. 22% (n = 22) in the cs-TIPS group. Ascites control and overall survival were better in the cs-TIPS (P = 0.0071). The gain in survival in the cs-TIPS patients occurred especially in patients with a baseline MELD score <16 (P < 0.0001). Post TIPS encephalopathy and ncs-TIPS were independently related with poor survival (P < 0.0001, P = 0.0150; respectively).

CONCLUSIONS

In cirrhotic patients with refractory ascites cs-TIPS offers better symptomatic control of the ascites at one year follow-up and a better overall survival, especially in patients with a MELD score of <16 at baseline.

Primary malignant fibrous histiocytoma of the pancreas: benefit of the multidisciplinary approach

Primary malignant fibrous histiocytoma (MFH) is an exceedingly rare tumour of the pancreas with a high recurrence rate and a poor prognosis. Only 11 cases have been reported in the past in the English literature. In this report, the authors present the case of a 45-year-old man who was first operated on for a primary MFH of the pancreas. Eleven months after the surgery, he was diagnosed with a tumoural recurrence presenting as hepatic and pulmonary metastasis. The patient underwent a multidisciplinary treatment of chemotherapy, percutaneous radiofrequency ablation, and a right hepatectomy combined with intraoperative radiofrequency ablation. Under multidisciplinary treatment, the patient fully recovered. He remains disease-free 3 years after his first surgery and 25 months after the recurrence. We report a case of a primary MFH of the pancreas treated by using a multidisciplinary approach resulting in an above average survival rate. Although further cases and longer follow-up periods are necessary to conclude about the role of multidisciplinary treatment in the long-term prognosis of primary MFH of the pancreas, we believe that multidisciplinary treatment could improve the survival rates of other patients.

Abstract 2606: Absence of transcriptomic signature of response to chemotherapy in metastatic colorectal carcinoma patients

Using whole genome tumour gene expression profiling in patients treated for metastatic colorectal cancer, we attempted to define a signature able to discriminate between responders and non-responders to first-line chemotherapy.

A total of 42 patients were prospectively included between 2003 and 2006. They all suffered from histologically proven colorectal adenocarcinoma and were metastatic at the time of diagnosis. All of them gave informed consent to the study. They were treated in first line with 5-fluorouracil (according to the de Gramont regimen in most cases) associated either with irinotecan (FolFiri regimen, 180 mg/m2 every two weeks, 22 pts) or with oxaliplatin (FolFox 4 regimen, 85 mg/m2, 20 pts) according to physician's decision. Response was evaluated using WHO criteria every 2 months after initiation of chemotherapy and patients were assigned to complete response (1 pt), partial response (24 pts), stable disease (13 pts) or progressive disease (4 pts).

From a tumour sample obtained at surgery (18 pts) or by biopsy (24 pts) and kept in RNA later, we extracted and purified total RNA. Gene expression profiling was performed by Cogenics using microarrays from Applied Biosystems (Human Genome Survey Microarray v2.0). We used three different methods for supervised data analysis: analysis of variance, SAM (statistical analysis of microarrays) and Limma (Bioconductor). We compared responders to non-responders in the whole set of patients and in the subsets of patients who received either irinotecan or oxaliplatin. With none of the three methods we were able to obtain a stable signature, i.e. a group of genes consistently associated with response to chemotherapy. On the contrary, we obtained very homogeneous gene expression profiles which were even difficult to clusterise using a non-supervised approach. These negative results show that the determinants of response to chemotherapy should be sought not only in the tumour molecular characteristics, but also among the processes leading to drug availability to the tumour (drug dose, drug disposition, etc.). Especially, the relatively low dose of irinotecan which is of standard use in Europe does not allow to recruit all the responders who could be identified at higher dosage, given the sharp dose-efficacy curve that has been identified long ago for this drug.

Note: This abstract was not presented at the AACR 101st Annual Meeting 2010 because the presenter was unable to attend.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 2606.

KRAS and BRAF mutational status in primary colorectal tumors and related metastatic sites: biological and clinical implications

BACKGROUND

KRAS and BRAF mutations in primary colorectal tumors (PT) are predictive of nonresponse to anti-epidermal growth factor receptor (EGFR) antibodies in patients with metastatic colorectal cancer (mCRC). The question of primary resistance to anti-EGFR treatment as a result of the presence of KRAS or BRAF mutations only in metastases has been raised but not resolved.

METHODS

We analyzed the mutational status of KRAS and BRAF in 64 new patients with mCRC and performed a systematic review of published data from 285 patients.

RESULTS

A total of 285 and 95 matched PT/metastases were available for the analysis of the KRAS and the BRAF status, respectively. An identical mutational pattern of KRAS in PT and the matching metastases were reported in all the cases but 14 (5%). In six cases (2%), KRAS was mutated in the PT and wild type in the metastatic site, whereas in eight cases (3%), KRAS was wild type in the PT and mutated in the metastatic site. An identical mutational pattern of BRAF in PT and the matching metastases was reported in all but two cases (3%). In one case (1.5%), BRAF was mutated in the PT and wild type in the metastatic site, whereas in one case (1.5%), BRAF was wild type in the PT and mutated in the metastatic site.

CONCLUSIONS

The acquisition by metastases of a KRAS or a BRAF mutation that was not present in the PT is a rare event, occurring in 5% of cases of mCRC. This is not a frequent mechanism of primary resistance to anti-EGFR treatments in mCRC.

An inhibitor of interleukin-6 trans-signalling, sgp130, contributes to impaired acute phase response in human chronic liver disease

In chronic liver disease, high circulating interleukin (IL)-6 contrasts with a poor acute phase response. We evaluated the impact of liver and circulating IL-6-receptor (IL-6R) forms on IL-6 bioactivity in chronic liver disease. IL-6, soluble IL-6-receptor and sgp130 levels were assayed in plasma from 45 patients with alcoholic liver disease, 84 with hepatitis C virus (HCV) infection undergoing transjugular liver biopsies and 15 healthy subjects. IL-6R mRNA was quantified on liver extracts from 54 patients with alcoholic liver disease with or without cirrhosis and 18 HCV-infected patients. The effect of gp130-Fc on fibrinogen secretion induced by IL-6 trans-signalling was evaluated on hepatocyte cultures. Levels of plasma IL-6 and sgp130, but not soluble IL-6R, increased with the stage of chronic liver disease, and correlated significantly with disease severity. Alcoholic liver disease patients had higher plasma IL-6 levels than hepatitis C, but lower liver IL-6R expression. In alcoholic and HCV-related liver diseases, liver IL-6R expression decreased with advanced fibrosis stage. In vitro, on hepatocytes, gp130-Fc blunted the acute phase response while soluble IL-6R enhanced IL-6 stimulation. In advanced chronic liver disease, high plasma IL-6 is associated with low liver IL-6R expression. This situation enables high plasma sgp130 to act as a major negative regulator of liver IL-6 trans-signalling, as demonstrated functionally here on hepatocytes. This might explain the poor acute phase response induced by IL-6 in chronic liver disease.

Efficacy of intraoperative radiofrequency ablation (IRFA) combined or not with resection to treat unresectable colorectal metastases, with or without preoperative chemotherapy: The ARF2003 Study (NTC 00210106): Preliminary results

4095

Background: Only few patients suffering from colorectal metastases (CRM) can have surgery and thus hope for a 40% 5-year survival rate. Adding IRFA to resection may improve the efficacy of surgery. Methods: The primary objective was to evaluate the efficacy of IRFA combined or not with resection in terms of 3-month complete hepatic response (CHR) in patients with unresectable CRM. Secondary endpoints were overall survival (OS), disease-free survival (DFS), morbidity and quality of life. A phase II study based on a Simon's two-stage design was conducted in 6 university French hospitals. Number of subjects estimated was 53, with 19 for the 1st stage. At the end of the 1st stage, 12 CHR were required to continue recruiting. At the end of 2nd stage, 37 CHR would be required to claim efficacy. Results: Fifteen of the first 19 patients exhibited CHR allowing the study to pursue accrual which ended in Nov 08; some patients are still followed up. As of Nov 08, data had been collected on 47 patients (mean age 61 years): 6 had RFA alone (13%), 37 had RFA and resections (82%), 2 could not be treated (4%). Median number of CRM was 5 (1–12). All had chemotherapy pre-op and 12 post-op (29%). Three-month data were available for 36 patients: 1 patient died on the 3rd week following intervention. Scans were available for 35 patients (independently reviewed). Of these, 29 had CHR (83%); 13 had 3-month morbidity (37%). The median follow-up was 15 months. One-year OS and DFS rates were 92.3% and 26% respectively. Analysis on all 53 patients will be communicated in June 09. Conclusions: These preliminary results suggest that IRFA combined or not to resection may be efficient in treating unresectable diseases despite their more aggressive pattern. This corroborates the EORTCC CLOCC Trial findings which demonstrated IRFA superiority upon chemotherapy alone. IRFA could thus be valuably associated to resection in treating patients with colorectal metastases that resection alone could not handle.

No significant financial relationships to disclose.

Cytokines pattern after surgical radiofrequency ablation of liver colorectal metastases

AIMS

The aim of this study was to evaluate the serum pattern of cytokines evolution after surgical radiofrequency ablation (SRFA) of colorectal metastases.

METHODS

Metastases of ten non consecutive patients were destroyed by radiofrequency ablation without concomitant resection after a complete surgical procedure including a laparotomy, a peritoneal examination, liver mobilisation and liver ultrasound. Serum levels of IL-6, TNFalpha, HGF, VEGF, bFGF, TGFbeta1 and CRP were assessed by ELISA assays at different time points.

RESULTS

TNFalpha and bFGF remained undetectable. IL-6 peaked at 3 hours and remained elevated during the entire study period. HGF increased by three-fold by Day 1 then decreased until Day 7 where it was still twice its baseline level. VEGF level increased from Day 5 onward. TGFbeta1 did not show significant variations. CRP was increased throughout the study.

CONCLUSIONS

In contrast with cryotherapy, SRFA does not lead to high serum TNFalpha suggesting a better tolerance. Nevertheless high IL-6, HGF and VEGF serum levels are characteristic of a general inflammatory stress which should be taken into account.

Could bipolar vessel sealers prevent bile leaks after hepatectomy?

BACKGROUND AND AIMS

The aim of this work was to test the feasibility of using a bipolar low thermal acting system inducing collagenic sealing but not protein coagulation to secure hepatic parenchyma cutting.

MATERIALS AND METHODS

Thirty consecutive hepatectomies were carried out using kellyclasy plus ligatures and clips (controls), while the following 50 hepatectomies used kellyclasy plus bipolar vessels sealer (BVS). Blood loss, duration of hepatic pedicle clamping, length of hospital stay, and complications were recorded.

RESULTS

There was no statistically significant difference in blood loss and duration of clamping between controls and BVS. Specific complications (9/21 in the control group vs 1/49 for the BVS group, p<0.00045) and length of hospital stay (14 days in the control group vs 11 days in the BVS group, p<0.014) were statistically lower in BVS group than in the controls, mainly due to prevention of bile duct leakages.

CONCLUSIONS

Our data suggest that BVS may be particularly efficient to achieve bilistasis leading to the highest level of safety in performing hepatectomies. Further studies are now needed to confirm its superiority on the classical biliary ducts occlusion techniques.

[Interest of selective lymphadenectomy in patients with vulvar cancer]

Vulvar cancer represents approximately 4% of all gynecologic malignancies and the most important prognosis factor in this cancer is the status of the regional lymph nodes. The radical inguinal lymphadenectomy, associated or not with radiotherapy, is accompanied by high morbidity, which can affect 50% of the patients. The sentinel node detection appears now to be feasible in patients with vulvar carcinoma, in order to reduce the morbidity of inguinal lymphadenectomy. But contrary to breast cancer, the learning curve is not easy to obtain because of the low number of cases. That is why we have described the procedure of selective lymphadenectomy. The aim of this technique is to remove the blue and/or marked inguinal lymph node and any other palpable lymph node, without a real radical inguinal lymphadenectomy. Thus, since November 2003, 4 procedures have been performed in total. With the lymphoscintigraphy, we identified 17 marked lymph node and we finally obtained 28 lymph nodes after surgery, with only one metastatic lymph node. There was no complication after our procedure. Selective lymphadenectomy appears to be a new procedure which may reduce the morbidity of usual inguinal lymphadenectomy.