Partial splenic embolization for hypersplenism in cirrhosis: a long-term outcome in 62 patients

BACKGROUND

Although partial splenic embolization (PSE) has been widely used for treatment of leucocytopaenia and thrombocytopaenia in cirrhosis, only few studies on the correlation between splenic infarction rate and long-term outcome of partial splenic embolization have been reported so far.

AIM

To evaluate long-term results of partial splenic embolization with different infarction rates in cirrhotic patients with hypersplenism.

METHODS

Sixty-two consecutive patients with hypersplenism in cirrhosis received partial splenic embolization. According to the splenic infarction rate after partial splenic embolization, the patients were divided into three groups: more than 70% in group A (n=12), 50-70% in group B (n=34), and less than 50% in group C (n=16). The post-partial splenic embolization following-up time was 5 years.

RESULTS

Before partial splenic embolization, there were no significant differences among the three groups with respect to sex, age, splenic volume, Child-Pugh class, oesophageal varices, and peripheral blood cell counts. After partial splenic embolization, the short- and long-term outcomes of leucocyte and platelet counts showed significant difference among the three groups (P<0.001). In groups A and B, the leucocyte and platelet counts after partial splenic embolization remained significantly higher than those before partial splenic embolization for 2 weeks to 5 years (P<0.05), the post-partial splenic embolization leucocyte and platelet counts was even higher in group A than in group B; while in group C, leucocyte and platelet count improvement only lasted for 6 months after partial splenic embolization. No significant changes were observed concerning blood red cell counts and liver function parameters after partial splenic embolization among the three groups. Severe complications occurred in six patients (50%) in group A and three patients (8.8%) in group B (P<0.05), while in group C, no severe complications developed.

CONCLUSIONS

In partial splenic embolization, the splenic infarction rate should be limited to 50%-70% in order to ensure the long-term efficacy in alleviating hypersplenism and reduce complications.

A novel mutant-enriched liquidchip for detection of circulating EGFR mutations in advanced non-small cell lung cancer patients

e14526

Background: We developed a novel technology, Mutant-enriched liquidchip (MEL), which integrates the sensitive mutant enriched PCR and quantitative high throughput liquidchip (suspension array), to detect circulating EGFR mutations (Exon 19 deletion and exon 21 L858R mutation) in patients with advanced non-small cell lung cancer (NSCLC). Methods: To enrich mutant EGFR, a unique restriction site is introduced into the mutation alleles so that the wild type sequence can be selectively removed by restriction digestion, and the undigested mutated DNA is amplified by PCR. The product is then hybridized to complementary probes (including 15 types of exon 19 deletion and exon 21 L858R mutation) which had been conjugated to beads coding with different fluorescent dye, followed by measuring through Luminex 200 system. Plasmid DNA mixture with different EGFR genotypes was applied to determine the sensitivity and accuracy of MEL. Afterwards, the MEL was validated in 49 patients whose EGFR genotypes of tissue specimen had been tested with direct sequencing The circulating genomic DNA was obtained from serum sample of other 201 Chinese stage IIIB or IV NSCLC patients without EGFR-TKI administration, and the EGFR mutation status was analyzed by using of MEL. Results: The results shows that MEL is capable of detecting as few as 20 copies of mutant EGFR alleles with a sensitivity limit of at least mutant/wild-type ratio of 0.1%. It also shows that MEL can not only confirm EGFR mutations status in tissue specimens already known by direct sequencing (13/49), but also detect mutations in some of those showing wild type by sequencing (16/49). Overall, 54% of patients had circulating EGFR mutation. 34% of patients had an exon 19 deletion and 29.6% had L858R. 63.1% of mutations were found in females and 67.6% in never-smokers. Conclusions: This novel MEL method allows for highly sensitive and reproducible detection of human somatic mutations in heterogeneous specimens, and could be applicable to test EGFR mutations non-invasively in advanced NSCLC patients for predicting response to targeted therapy.

No significant financial relationships to disclose.

Single- versus multiple-item assessment of quality of life in patients with advanced cancer

e20528

Background: The main objective of palliative cancer care is to improve quality of life (QOL). As multiple dimensions impact on the construct of QOL, multi-dimensional instruments are usually used in its measurement. These are time consuming and burdensome for repeated use. Recent authors have suggested that brief single-item global assessments can provide a reliable measure of QOL. We assessed the performance of the Edmonton Symptom Assessment System ‘feeling of well-being’ item (ESAS WB) using the Functional Assessment of Cancer Therapy - General (FACT-G) instrument as a gold standard. Methods: After obtaining IRB approval, we reviewed the data from 213 advanced cancer patients who had participated in six studies from March 2006 to June 2008 and determined the level of association between baseline ESAS WB and FACT-G total score and subscale domains (Physical (Pwb), Social/Family (Swb), Emotional (Ewb), and Functional (Fwb) Well-Being) and also the 9 ESAS symptom intensity scores using Spearman correlation coefficients. We also calculated the change between the baseline (T1) and second (T2) observations of ESAS WB and of FACT-G total score and determined their level of association using a Pearson correlation coefficient. In addition, we predicted the change in FACT-G as predicted by the change in ESAS WB score using regression analysis. Results: Mean age was 60 (SD 12) years and 48% were female. At T1, the Spearman correlation coefficient of ESAS WB and FACT-G was -0.48 (p<0.0001). Spearman correlation coefficients for ESAS WB and FACT-G subscale domains and ESAS symptom intensity scores were also highly significant (p<0.0001) for all physical and emotional symptoms (other than p=0.003 for nausea) except for FACT Swb (p=0.08). The Pearson correlation coefficient for difference between T1 and T2 in ESAS WB and FACT-G for 146 patients was -0.36 (p<0.0001). The regression analysis was highly significant (p<0.0001). The change in ESAS WB corresponding to FACT-G published minimally important difference (MID) was -0.24 for 3, -1.55 for 5, and -2.87 for 7, respectively. Conclusions: ESAS WB is a practical instrument for clinical use and best reflects the Pwb, Ewb and Fwb domains of FACT-G as compared to Swb.

No significant financial relationships to disclose.

Utilization of antineoplastic therapy (ANT) in advanced cancer patients admitted to an acute palliative care unit (APCU) at a comprehensive cancer center

9590

Background: Cancer patients admitted to a palliative care unit generally have a poor prognosis. The role of ANT (chemotherapy and targeted agents) in these patients is unclear. We examined the frequency, trends, factors and survival associated with ANT use in hospitalized patients who required an APCU stay. Methods: All patients admitted to APCU between September 1, 2003 and August 31, 2008 were included. Demographics, cancer diagnosis and ANTs utilization from day of hospitalization to discharge, and survival information were retrieved retrospectively. Results: 2604 cancer patients had the following characteristics: median age 59 (range 18–101), male 51%, hematologic malignancy 11%, median hospital stay 11 (Q1-Q3 8–17) days, median APCU stay 7 (Q1-Q3 4–10) days and median survival 22 days. During hospitalization, 393 patients (15%) received ANTs, including chemotherapy (N=297, 11%) and targeted therapy (N=155, 6%). No significant change in frequency of ANTs was detected over the 5 year period. Multivariate logistic regression analysis ( Table ) revealed that younger age, cancer primaries and longer admissions were associated with ANT use. Patients with hematologic malignancies received more chemotherapy (38% vs. 8%, p<0.001) and targeted agents (18% vs. 4%, p<0.001) compared to patients with solid tumors. ANT use was associated with longer overall survival in univariate analysis (median 25 days vs. 21 days, p=0.001); however, this was no longer significant in multivariate Cox regression analysis. Conclusions: The use of ANT during hospitalization that included an APCU stay was limited to a highly selected group of patients, and did not increase overtime. ANT use was associated with younger age, specific cancer primaries, longer admissions, and no significant improvement in survival. The APCU at our cancer center facilitates simultaneous care where patients access palliative care while on ANT. [Table: see text]

No significant financial relationships to disclose.

Use of CA9 gene single nucleotide polymorphisms to predict prognosis and treatment response of metastatic renal cell carcinoma

5003

Background: Carbonic anhydrase 9 gene (CA9) is located in a prognostically relevant chromosomal area on chromosome 9p and is encoding for one of the most significant protein markers in metastatic renal cell carcinoma (MRCC), CAIX. In contrast to CAIX protein, however, no efforts have been made to date to study CA9 gene in metastatic RCC. Here, we test the hypotheses that single nucleotide polymorphisms (SNPs) and mutations of the CA9 gene are associated with CAIX expression, response to immunotherapy and survival. Methods: Genomic DNA was extracted from frozen tumor samples of 54 patients with clear cell MRCC. All exons of the CA9 gene were PCR-amplified and sequenced. The antibody M75 was used to evaluate CAIX protein expression immunohistochemically. Statistical associations of CA9 gene status and CAIX protein expression with response to IL-2 based immunotherapy and overall survival were assessed with chi-square tests, t-tests, Kaplan-Meier survival estimates and Cox proportional hazards regression models. Results: CA9 reference SNP (rs) 2071676 was found in 59%, rs12553173 in 15%, rs3829078 in 11% and rs1048638 in 33% of the patients. The deletion c.376del393 was observed in two patients. CAIX expression was high (>85%) in 65% of the patients. None of the SNPs was significantly associated with CAIX expression. Patients with the C allele variant of rs12553173 had improved median survival (27.3 vs. 13.6 months, p = 0.0431) and a greater likelihood of response to IL-2 (57% vs. 22%, p = 0.081) Likewise, high CAIX expression was associated with longer median survival (25.5 vs. 8.5 months, p < 0.0001) and a greater IL-2 response rate (37% vs. 8%, p = 0.070). In a multivariate Cox model, both C allele variant of CA9 SNP rs12553173 and CAIX expression were retained as independent prognostic factors. Conclusions: CA9 SNPs are frequently found in patients with MRCC. The C allele variant of rs12553173 is associated with improved overall survival and a greater likelihood of response to IL-2. CA9 rs12553173 and CAIX are both independent prognostic factors of overall survival and complementary in predicting prognosis of MRCC.

No significant financial relationships to disclose.

Acute palliative care unit in a comprehensive cancer center (CCC): Financial and clinical outcomes

e20518

Background: Acute palliative care units (APCU) in CCCs improves symptom control for advanced cancer patients and supports their families. However, these services are not available in the majority of cancer centers. Concerns regarding financial reimbursements represent a major barrier for establishing APCUs. The purpose of this study is to report the clinical outcomes and compare the financial outcomes of our APCU as compared to other services at our CCC. Methods: We reviewed all admissions to the APCU over the last 5 fiscal years for demographic information, length of stay, discharges, survival, hospital billings and collection of charges, and compared these to the rest of the institution. Results: 2,510 unique patients were admitted to the APCU. Median age was 59 years (19–101) and 51% were female. The median length of stay in APCU was 8 days (Q1-Q3 6–10). Median survival of patients discharged home, to health care facilities and hospice were 53, 22, and 13 days, respectively (p<0.001, log rank test), with 6 month survival of 20%, 4%, and 2%, respectively. Professional collections ranged from 42–47% of charges for APCU, vs. 32–38% for rest of the CCC and were stable over the 5 year period. Hospital collections were 47–51% of charges for APCU, vs. 55–57% for the rest of the CCC. The payer mix included commercial 1155 (46%), Medicare 755 (30%), Medicaid 126 (5%), mixed 127 (5%), indigent 198 (8%), and others 149 (6%). Conclusions: The ACPU has reimbursement outcomes consistent with the American acute care model and comparable to the rest of the CCC for last 5 years. The APCU is as viable as any other clinical programs in our institution. Further research is needed to investigate possible reasons for lack of APCU in cancer centers.

No significant financial relationships to disclose.

Treatment experience of subsequent complications after Roux-en-Y biliojejunostomy

PURPOSE

Roux-en-Y biliojejunostomy has been frequently used in the management of benign biliary disease. The aim of this study was to summarize one institute's experiences in prevention and management of subsequent complications of Roux-en-Y biliojejunostomy.

METHODS

A retrospective analysis was carried out for patients who underwent reoperation after Roux-en-Y biliojejunostomy from February 1990 through June 2004. Operation history, laboratory test data before the last operation, and images were collected.

RESULTS

Sixty-one patients, aged 36-60 years and with a 3.5-year average operation interval, were involved in the study. Anastomotic stricture (47, 80.3%), recurrent calculi (36, 60.7%), and biliary tract infection (all) were the most common complications after Roux-en-Y biliojejunostomy. Other complications (such as calculi of the intrahepatic duct or intrahepatic duct stricture, malformed or twisted jejunum loop, too long or too short proximal jejunum, disappearance of the normal form of anastomosis, and adhesion of the intestinal loop) were also detected by laparotomy.

CONCLUSION

Calculus, stricture, and infection arise as a result of each other. Lessening of the anastomotic stricture, fluent drainage of the distal jejunum below the anastomosis, and relieving pressure of gastrointestinal tract are pivotal in decreasing subsequent complications after Roux-en-Y biliojejunostomy.