[Adjuvant therapy of pancreatic carcinoma]

The poor prognosis in pancreatic carcinoma has been increased especially by improved diagnostic procedures and decreasing perioperative mortality. Median survival after complete resection is commonly less than 20 months and the 5 years survival is in the range of about 20%. Postoperative radiochemotherapy reduces the local recurrence rate but not the overall survival however. Pancreatic carcinoma is characterized by a low chemosensitivity of the drugs commonly used like 5-FU. More aggressive chemotherapy protocols are limited by the reduced status of the patient. Multimodal and prolonged adjuvant schedules did not show a prognostic benefit. The current ESPAC--study investigates the role of simultaneous radiotherapy and 5-FU alone or in combination with neoadjuvant 5-FU and folic acid for 6 months. New protocols will investigate the value of regional adjuvant chemotherapy ESPAC 2) [44] and of gemcitabine, 5-FU or control in a three arm study.--In a multicenter German trial the benefit of gemcitabene as weekly monotherapy for 6 months is investigated. The treatment starts soon after resection due to low toxicity and good patient compliance.

The role of gemcitabine alone and in combination in the treatment of pancreatic cancer

Pancreatic cancer, one of the most frequently reported gastrointestinal tumors, has a 5-year survival of less than 5%. Despite representing only 2-3% of the total cancer incidence, it is the fifth leading cause of cancer death. This is because it is commonly only diagnosed at an advanced stage. Until recently the traditional therapy for patients with advanced disease was palliative 5-fluorouracil (5-FU)-based chemotherapy. However, the novel antinucleoside gemcitabine (Gemzar) has demonstrated a survival benefit over 5-FU, and an improvement in disease-related symptoms and quality of life in patients with advanced disease. This review presents an overview of the clinical studies of gemcitabine, either alone or in combination, with other chemotherapeutic agents and/or radiation therapy, in the treatment of these patients. A comparison of these studies is made with those using alternative treatment regimens. The data suggest that gemcitabine in combination with biomodulated 5-FU should be considered the standard palliative treatment to which other new drug combinations or combined modality chemoradiation regimens should be compared.

[The importance of delay in patients with tumors exemplified by pretreatment of locally advanced rectal carcinoma]

BACKGROUND

With the intention to achieve tumor reduction and thereby increase R0-resection rate, preoperative radiochemotherapy is increasingly applied in locally advanced rectum cancer. Along with the advantages of prior therapy, a delay of surgical treatment occurs which might despite continuing therapy give way to local tumor progression or metastatic disease.

PATIENTS AND METHODS

Since 1993 we have treated locally advanced rectum carcinomas by preoperative radiotherapy according to a preoperative study protocol. We analyzed the incidence of local tumor progression or metastases during the 12 weeks of preoperative treatment. Hundred and fifteen patients with histologically proven primary rectum carcinoma without evidence of regional or distant metastases and endosonographically determined infiltration depth of stage T3 or more underwent preoperative radiochemotherapy between 3/1993 and 10/1999. Hundred and eight patients (88 times uT3 and (20 times uT4) have been operated and examined afterwards with respect to response to prior treatment. Before and after preoperative therapy, endorectal ultrasound was performed to evaluate local response. Distant metastatic manifestations were excluded by radiography and ultrasound scanning.

RESULTS

A reduction of the infiltration depth was observed in 55 patients (51%). Tumor size remained unchanged in 50 patients (46%). Only 3 patients (3%) showed tumor growth in histological assessment. Fifty-seven patients (53%) showed no change in lymph node status after preoperative therapy, whereas lymph node metastases were detected in 11 patients (10%) who were judged uN0 preoperatively. We discovered metastases in 6 patients (6%) after preoperative therapy.

CONCLUSION

During preoperative therapy, tumor progress is not entirely evitable. Considering the lack of precision in pretherapeutic staging diagnostics, we conclude that delays due to therapeutic regimen are responsible for prognostic disadvantage in only a small number of patients.

A phase II trial of gemcitabine in combination with 5-fluorouracil (24-hour) and folinic acid in patients with chemonaive advanced pancreatic cancer

BACKGROUND

Gemcitabine (Gemzar) and 5-fluorouracil (5-FU) plus folinic acid (FA) both have proven activity in the treatment of patients with advanced pancreatic cancer. The present study was initiated to investigate the efficacy of gemcitabine in combination with 5-FU-FA.

PATIENTS AND METHODS

Thirty-eight patients, median age 60 years (range 34-70) with inoperable, stage IV, pancreatic cancer were enrolled into the study and treated on an outpatient basis. All except one patient received at least one cycle of treatment with gemcitabine (1000 mg/m2), followed by FA (200 mg/m2) and 5-FU (750 mg/m2) administered as a 24-hour continuous infusion on days 1, 8, 15 and 22 of a 42-day schedule. No patient had received prior chemotherapy or radiotherapy. All 38 patients were assessed for efficacy, toxicity and time to progressive disease.

RESULTS

Two patients (5%), achieved a partial response and thirty-four patients (89%) achieved stable disease. There were two early deaths (< or = 4 weeks). The median time to progression was 7.1 months (range 0.4-18.1+; 95% confidence interval (95% CI): 5.3-7.9 months). Three patients had a progression-free interval of greater than 12 months and 12 of 38 patients (32%) survived longer than 12 months. The median overall survival was 9.3 months (range 0.5-26.5; 95% CI: 7.3-13.0 months). The incidence of grade 3 and 4 toxicities was low.

CONCLUSIONS

The combination of gemcitabine and 5-FU-FA is active and well tolerated and seems to offer an improvement in progression-free interval over both gemcitabine monotherapy and 5-FU-FA therapy.

Primary mucinous adenocarcinoma of the appendix: a rare entity in the differential diagnosis of ovarian cancer

We report a 58-year-old female patient with the suspected diagnosis of ovarian cancer. Upon surgical exploration, examination of the appendix revealed the histological diagnosis of primary mucinous adenocarcinoma. This is an unusual consideration in the differential diagnosis of the ovarian cancer. We discuss the diagnosis, classification and treatment of the cancer of the appendix in relation to ovarian cancer.

Paclitaxel as weekly second-line therapy in patients with advanced pancreatic carcinoma

Although the prognosis for patients with pancreatic adenocarcinoma is still poor, gemcitabine has shown significant impact upon survival and quality of life. Our aim was to examine the potential effectiveness of a second- or third-line therapy with paclitaxel (Taxol) after confirmed progression with a gemcitabine-containing schedule for patients remaining in good clinical condition. Eighteen patients with stage IVb disease participated in this study. Pretreatment with gemcitabine was performed either as monotherapy and/or in combination with 5-fluorouracil (5-FU) and folic acid (FA). Paclitaxel was administered at weekly intervals on an outpatient basis. We observed 238 weekly treatments with a median number per patient of 12 treatments. The median dosage was 73 mg/m2 paclitaxel (range 55-88 mg/m2). Regarding toxicity, only one patient each presented with anemia and leukocytopenia of WHO grade III. Hepatotoxicity with a temporary increase in aminotransferase of WHO grade II occurred in three patients. Higher-grade symptomatic toxicity was rare, except alopecia. At this time, the median survival time is 17.5 weeks (range 7-88 weeks) since the start of therapy. Stable disease was observed in five patients. One patient achieved complete remission within 37 weeks. At this time, he has survived for more than 56 weeks after confirmed progression under first-line therapy. In conclusion, this schedule demonstrates that weekly therapy with paclitaxel after pretreatment can be effective with a low toxicity profile. This opens up an additional therapeutic option for a selected patient group with a poor prognosis so far.

Preoperative radiochemotherapy in locally advanced or recurrent rectal cancer: regional radiofrequency hyperthermia correlates with clinical parameters

PURPOSE

Preoperative radiochemotherapy (RCT) is a widely used means of treatment for patients suffering from primary, locally advanced, or recurrent rectal cancer. We evaluated the efficacy of treatment due to additional application of regional hyperthermia (HRCT) to this conventional therapy regime in a Phase II study, employing the annular phased-array system BSD-2000 (SIGMA-60 applicator). The clinical results of the trial were encouraging. We investigated the relationship between a variety of thermal and clinical parameters in order to assess the adequacy of thermometry, the effectiveness of hyperthermia therapy, and its potential contribution to clinical endpoints.

METHODS AND MATERIALS

A preoperative combination of radiotherapy (1.8 Gy for 5 days a week, total dose 45 Gy applied over 5 weeks) and chemotherapy (low-dose 5-fluorouracil [5-FU] plus leucovorin in the first and fourth week) was administered to 37 patients with primary rectal cancer (PRC) and 18 patients with recurrent rectal cancer (RRC). Regional hyperthermia (RHT) was applied once a week prior to the daily irradiation fraction of 1.8 Gy. Temperatures were registered along rectal catheters using Bowman thermistors. Measurement points related to the tumor were specified after estimating the section of the catheter in near contact with the tumor. Three patients with local recurrence after abdominoperineal resection, had their catheters positioned transgluteally under CT guidance, where the section of the catheter related to the tumor was estimated from the CT scans. Index temperatures (especially T(max), T(90)) averaged over time, cumulative minutes (cum min) (here for T(90) > reference temperature 40.5 degrees C), and equivalent minutes (equ min) (with respect to 43 degrees C) were derived from repetitive temperature-position scans (5- to 10-min intervals) utilizing software specially developed for this purpose on a PC platform. Using the statistical software package SPSS a careful analysis was performed, not only of the variance of thermal parameters with respect to clinical criteria such as toxicity, response, and survival but also its dependency on tumor characteristics.

RESULTS

The rate of resectability (89%) and response (59%) were high for the PRC group, and a clear positive correlation existed between index temperatures (T(90)) and thermal doses (cum min T(90) >/= 40.5 degrees C). Even though the overall 5-year survival was encouraging (60%) and significantly associated with response, there was no statistically significant relationship between temperature parameters and long-term survival for this limited number of patients. However, nonresectable tumors with higher thermal parameters (especially cum min T(90) >/= 40.5 degrees C) had a tendency for better overall survival. We found even higher temperatures in patients with recurrences (T(90) = 40.7 degrees C versus T(90) = 40.2 degrees C). However, these conditions for easier heating did not involve a favorable clinical outcome, since surgical resectability (22%) and response rate (28%) for the RRC group were low. We did not notice any other dependency of thermal parameters to a specific tumor or patient characteristics. Finally, neither acute toxicity (hot spots) induced by hyperthermia or RCT nor perioperative morbidity were correlated with temperature-derived parameters. Only a higher probability for the occurrence of hot spots was found during treatment with elevated power levels.

CONCLUSION

In this study with two subgroups, i.e., patients with PRC (n = 37) and RRC (n = 18), there exists a positive interrelationship between thermal parameters (such as T(90), cum min T(90) >/= 40,5 degrees C) and clinical parameters concerning effectiveness. Additional hyperthermia treatment does not seem to enhance toxicity or subacute morbidity. Procedures to measure temperatures and to derive thermal parameters, as well as the hyperthermia technique itself appear adequate enough to classify heat treatments in

[Imaging of intra-arterial hepatic port catheter systems by power-doppler sonography using contrast media--preliminary results]

AIM

This study was designed to determine whether intra-arterial hepatic port catheter systems can be adequately detected by contrast-enhanced power-Doppler sonography.

METHOD

15 patients with a liver port system were investigated before chemotherapy. Examinations were performed with short bolus injections of the contrast medium Levovist in addition to angiographic imaging.

RESULTS

Liver port systems were easily detected by the contrast-enhanced power-Doppler method. In 11 out of 15 patients a correct flow of the contrast medium via the port system was seen with both examination methods. One partially occluded hepatic artery was not identified by power-Doppler despite correct flow of the contrast fluid. In one of three patients showing an incorrect flow of the contrast medium the blood circulated primarily through the splenic artery due to a dislocation of the catheter tip. Circulation through both the hepatic and the splenic arteries was shown in a second patient and an occluded right hepatic artery was demonstrated in a third. All these findings were observed with both examination techniques.

CONCLUSION

Power-Doppler sonography provides a reliable image of the port catheter system. This method can be used as a follow-up procedure to determine the state of arterial hepatic circulation during chemotherapy.

[Preoperative radiochemotherapy of rectal carcinoma. Current status]

BACKGROUND

In locally advanced rectal cancer RO-resectability is limited and outcome is combined with a relatively high rate of local recurrences. This paper focuses on experiences with preoperative (neo-)adjuvant therapy and the potential improvement of treatment results.

PATIENTS AND METHODS

Different therapy regimen were demonstrated under consideration of therapeutic induced side effects, treatment response (downstaging) in relation to resectability, recurrence free and overall survival.

RESULTS

The rate of treatment induced toxicity of preoperative radio-(chemo-)therapy in locally advanced rectal cancer is acceptable with regard to the obtained treatment results. Through the pretreatment it was possible to gain a downstaging by nearly 60%. The frequency of local recurrence is significantly reduced by preoperative radiotherapy, and combined radiochemotherapy possibly increases the disease free survival. In what extent the results of treatment could be improved through hyperthermia and/or consecutive postoperative chemotherapy, is proved at present.

CONCLUSIONS

Preoperative radio-(chemo-)therapy should be increasingly introduced into the standard treatment regimen of locally advanced rectal cancer and has to be optimised within the scope of further studies.

Feasibility and analysis of thermal parameters for the whole-body-hyperthermia system IRATHERM-2000

The infrared system IRATHERM-2000, with water-filtered infrared A wavelength underwent 20 treatments of whole body hyperthermia in conjunction with chemotherapy. In all the sessions, the aimed systemic temperature (41.8 degrees C, maximum 42.0 degrees C) could be achieved and maintained for 60 min. Due to increasing clinical experience, the unnegligible local toxicity, exhibited as heat-induced superficial lesions, and neurotoxicity, could be reduced during the course of the study. Data from three other series accomplished at the von Ardenne Clinic, totalling 120 heat sessions, were available and included for a comparative analysis. Analysis of the toxicity shows that a correlation exists between thermal side-effects and heat-up periods (until steady-state), maximum temperatures, and superficial thermal doses. The time needed to reach the plateau seems to correlate with fluid loss, which, thus, indirectly influences toxicity, and most importantly the initial power level. The typical heat-up time in such a standard set-up amounts to 100-150 min, for a temperature rise from 37.5 to 42.0 degrees C. Evaluation of the energy balance reveals a highly patient-specific range for the reactive evaporation in the IRATHERM system, resulting in a power (heat) loss of up to 1400 W via sweat production of approximately 2 l/h. In order to counterbalance this effect, an accordingly high infrared power, ranging from 1200-1500 W, needs to be delivered, resulting in a significant thermal skin exposition. Concepts used to reduce the heat loss by reactive evaporation include prevention of convection by appropriate sealing of the heating chamber and increasing the humidity by a nebulizer. For the more trained user, the heat-up time can be considerably shortened, particularly, in the introductory phase of the heating process, by employing higher, but still tolerable, patient-specific power levels. However, such a strategy requires, due to higher risks, close monitoring of skin temperatures together with a considerable amount of clinical experience. The results of the IRATHERM pilot study were compared, not only with previous groups where the IRATHERM was applied, but also with results of various other investigators where the Enthermics Radiant Heat Device was employed. In the authors' opinion, improved understanding of the mechanisms and crucial parameters underlying whole body hyperthermia, will enable a controllable and tolerable therapy through proficient contribution to equipment and methods.

Behandlung der tiefen Venenthrombose

Von den verschiedenen, zur Behandlung der tiefen Venenthrombose zur Verfügung stehenden Optionen, stellt die akute Antikoagulanzientherapie mit Heparinen, insbesondere niedermolekularen Heparinen, gefolgt von der frühzeitig überlappend eingeleiteten oralen Antikoagulation, das Standardvorgehen dar. Thrombolyse, Thrombektomie und Implantation von Kavaschirmfiltern kommen nur bei wenigen Patienten sinnvoll in Betracht. Während somit die medikamentöse Therapie mit Heparinen und Cumarinen die medikamentöse Standardbehandlung darstellt, sind begleitende Therapiemaßnahmen, wie die Notwendigkeit zur initialen Immobilisation der Patienten sowie zur Kompressionsbehandlung bei tiefen Venenthrombosen in ihrer Wertigkeit ungesichert und Gegenstand kontroverser Diskussionen. Darüber hinaus werden die optimale Dauer der oralen Antikoagulation, der Stellenwert einer prolongierten Therapie mit niedermolekularen Heparinen sowie der Stellenwert neuerer Antithrombotika wie Antithrombine, Faktor-Xa-Hemmstoffe und »Tissue factor pathway inhibitor« diskutiert.

Activated protein C resistance shows an association with pregnancy-induced hypertension

A common mutation in the factor V gene, the Leiden mutation, is the most frequent genetic cause of resistance to activated protein C (APC). Recent studies have shown that the prevalence of APC resistance is associated with severe pregnancy-induced hypertension (PIH). Our objective was to determine whether the factor V Leiden mutation is more prevalent in patients who developed severe PIH than in normotensive pregnant women. In 70 women with a history of severe PIH, of whom 15 had pre-eclampsia, we investigated common coagulation factors as well as APC resistance (factor V related). We found that seven of these 70 women showed low values for APC. Out of these, five were heterozygous and none was homozygous for factor V Leiden mutation. In a control group of normotensive pregnant women we found a 3.0% rate of APC resistance and a 3.0% rate of carriers of the Leiden mutation. These results indicate a significantly higher prevalence of both APC resistance and factor V Leiden mutation in women with severe PIH. Placental infarctions and micro-embolisms are considered to be one of the principle pathophysiological changes in severe PIH. Our results suggest that APC resistance is a risk factor for severe PIH, in addition to its well-known role in macrothrombo-embolism.

Accuracy of endorectal ultrasound after preoperative radiochemotherapy in locally advanced rectal cancer

OBJECTIVES

Factors limiting the accuracy of endorectal ultrasound in staging, locally advanced primary rectal cancer after preoperative neoadjuvant radiochemotherapy (RCT) were evaluated.

METHODS

Patients (n = 84) with initial locally advanced rectal cancer (uT3/uT4) undergoing R0 resection were investigated after preoperative treatment that combined radiotherapy up to 45 Gy with two cycles of chemotherapy (5-FU and leucovorin on d 1-5 and 22-28). At 4 to 6 weeks after completion of RCT and before tumor resection, preoperative endoluminal ultrasound was performed.

RESULTS

The accuracy to predict the depth of tumor infiltration (T-category) was found to correlate with downstaging. The T-category was correctly staged before surgery in 15 of the 51 responders (29%) and in 27 of 33 nonresponders (82%), whereas misinterpretation occurred in 36 of the responders (71%) and in 6 of the nonresponders (18%) (p < 0.001). Neither tumor distance from anal verge nor tumor location correlated with the staging accuracy. Lymph node involvement was correctly assessed in 48 patients (57%). Wall invasion was correctly ascertained in 42 patients (50%), with under estimation in 11 patients (13%) and overestimation in 31 patients (37%).

CONCLUSIONS

After radiochemotherapy, endosonography does not provide a satisfactory accuracy for preoperative staging of rectal cancer. New interpretation and diagnostic criteria are needed for the prediction of treatment response.

Phase I trial of gemcitabine (Gemzar), 24 h infusion 5-fluorouracil and folinic acid in patients with inoperable pancreatic cancer

Gemcitabine (Gemzar) has a significant impact upon survival and quality of life for patients with pancreatic cancer, compared with 5-fluorouracil (5-FU). This phase I study was initiated to define the recommended dose of 5-FU delivered as a 24 h infusion in combination with gemcitabine (1000 mg/m2) and folinic acid (200 mg/m2) in patients with inoperable pancreatic cancer, treated on an outpatient basis. Drugs were administered weekly for 4 weeks out of 6 weeks. Sixteen chemonaive patients (median age 59 years, range 51-66) were enrolled, 15 had stage IV and one stage III disease. The median Karnofsky performance score (KPS) was 70 (range 60-80). Six patients received 5-FU 750 mg/m2, eight received 5-FU 1000 mg/m2 and two received 5-FU 1250 mg/m2. The maximum tolerated dose of 5-FU was 1000 mg/m2. Hepatotoxicity was dose limiting. One patient who received 5-FU 1250 mg/m2 died as a result of hepatorenal failure. There was one partial response, nine patients had stable disease for more than 3 months and 13 patients had improved KPS. The median time to progressive disease was 31 weeks (range 5-50 weeks). A phase 11 trial is underway to further assess the activity of this combination at the recommended dose of 750 mg/m2 5-FU.

Whole body hyperthermia: a secure procedure for patients with various malignancies?

OBJECTIVE

To establish the safety of systemic Cancer Multistep Therapy (sCMT) including whole body hyperthermia, by means of hemodynamic, laboratory and clinical investigations.

DESIGN

Prospective study.

SETTING

University clinic.

PATIENTS

12 patients with various cancers (with sCMT), a second group of 20 patients with colorectal carcinoma treated with chemotherapy (without sCMT).

INTERVENTIONS

25 treatments with sCMT for 60 min at 41.8 degrees C (including chemotherapy) were given in addition to induced hyperoxemia and hyperglycemia under general anesthesia.

MEASUREMENTS AND RESULTS

Invasive monitoring of systemic and pulmonary hemodynamics as well as pulmonary gas exchange was used at 37 degrees C, 40 degrees C, 41.8 degrees C and 39 degrees C. In addition, laboratory parameters were measured before and within 4 days of therapy. At 41.8 degrees C, invasive monitoring showed characteristic signs of hyperdynamic circulation. In addition, right-to-left shunt, oxygen consumption, oxygen delivery and lactate levels were significantly different from pretreatment values. At the end of therapy, lactate levels and the extravascular lung water index increased, whereas all other parameters showed a clear tendency to return to initial values. Within the first day after sCMT, we measured a slight but significant reversible increase in serum creatinine compared to pretreatment values, but found no significant alterations of other chemical parameters. Between the sCMT group and controls, there was only a temporary significant difference in aspartate aminotransferase levels 2 days after therapy.

CONCLUSIONS

sCMT, including whole body hyperthermia, accompanied by suitable anesthesiological management and monitoring, does not lead to any serious or sustained organ dysfunction and can therefore be regarded as a safe therapy.

Elevated reticulocyte count--a clue to the diagnosis of haemolytic-uraemic syndrome (HUS) associated with gemcitabine therapy for metastatic duodenal papillary carcinoma: a case report

In adults, the haemolytic-uraemic syndrome (HUS) is associated with probable causative factors in the minority of all cases. Cytotoxic drugs are one of these potential causative agents. Although metastatic cancer by itself is a recognized risk-factor for the development of HUS, therapy with mitomycin-C, with cis-platinum, and with bleomycin carries a significant, albeit extremely small, risk for the development of HUS, compared with all other cytotoxic drugs. Gemcitabine is a novel cytotoxic drug with promising activity against pancreatic adenocarcinoma. We are reporting on one patient with metastatic duodenal papillary carcinoma developing HUS while on weekly gemcitabine therapy. The presenting features in this patient were non-cardiac pulmonary oedema, renal failure, thrombocytopenia and haemolytic anaemia. The diagnosis of HUS was made on the day of admission of the patient to this institution. Upon aggressive therapy, including one single haemodialysis and five plasmaphereses, the patient recovered uneventfully, with modestly elevated creatinine-values as a remnant of the acute illness. Re-exposure to gemcitabine 6 months after the episode of HUS instituted for progressive carcinoma, thus far has not caused another episode of HUS.