Added value of diffusion-weighted imaging to MR cholangiopancreatography with unenhanced mr imaging for predicting malignancy or invasiveness of intraductal papillary mucinous neoplasm of the pancreas

PURPOSE

To investigate the added value of diffusion-weighted imaging (DWI) to magnetic resonance cholangiopancreatography (MRCP) with unenhanced MR imaging for predicting the malignancy or invasiveness of intraductal papillary mucinous neoplasms (IPMNs).

MATERIALS AND METHODS

Following Institutional Review Board (IRB) approval, this retrospective study included 52 patients with surgically resected IPMNs and who underwent MRCP, unenhanced MRI, and DWI. Three blinded radiologists evaluated the two image sets, ie, MRCP with unenhanced MR images vs. the combined set with MRCP, unenhanced MR images, and DWI, and scored their confidence for malignancy or for invasiveness of IPMNs. The mean apparent diffusion coefficient (ADC) values of benign IPMNs and of intraductal mucinous carcinomas (IPMCs) were compared. The diagnostic accuracy was calculated using receiver operating characteristic (ROC) curve analysis.

RESULTS

The mean ADC of malignant IPMNs (2.05 ± 0.66 × 10(-3) mm(2) /sec) was significantly lower than that of benign IPMNs (2.95 ± 0.32 × 10(-3) mm(2) /sec, P < 0.0001). Invasive IPMCs (1.51 ± 0.32 × 10(-3) mm(2) /sec) showed significantly lower ADC than that of noninvasive IPMCs (2.67 ± 0.23 × 10(-3) mm(2) /sec, P = 0.0003). The area of diffusion restriction was more frequently seen in malignant IPMNs than in benign IPMNs (P < 0.00001). The addition of DWI to MRCP with unenhanced MRI did not show a significant improvement for predicting malignant IPMN (P> 0.05), but resulted in a tendency to improve the diagnostic accuracy for the prediction of invasive IPMN in two observers (P = 0.072, P = 0.085).

CONCLUSION

The addition of DWI to MRCP with unenhanced MRI may improve the diagnosis of malignant IPMN and further increase the prediction of invasive IPMC.

Locally advanced rectal cancer: value of ADC mapping in prediction of tumor response to radiochemotherapy

PURPOSE

To evaluate the diagnostic performance of quantitative apparent diffusion coefficient (ADC) measurements, in the assessment of the therapeutic response to chemo-radiation therapy (CRT) in patients with locally advanced rectal cancer, by analyzing post CRT values of ADC, in relation to tumor regression grade (TRG) obtained by histopathologic evaluation of the rectal specimen.

METHODS

This prospective study was approved by an Institutional Review Board, and informed consent was obtained from all patients. Thirty-one patients with locally advanced rectal cancer underwent pre and post CRT MR imaging at 1.5T. ADC values were measured in regions of interest (ROIs) drawn independently by two radiologists, blinded to the pathology results, on three slices of the pre and post CRT DW-MR image sets with the corresponding T2 weighted images (T2WI) available for anatomic reference. The two readers' measurements were compared for differences in ADC values, inter-observer variability (measured as the intraclass correlation coefficient; ICC) and the ADC distributions of responders vs non-responders. The diagnostic performance of ADC in the prediction of the response to CRT was evaluated by calculating the area under the ROC curve (AUC) and the optimal cut-off values. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were assessed.

RESULTS

The two readers showed an overall strong agreement in measuring ADC values. For both readers, no differences in ADC pre-treatment measurements were observed between responders and non-responders. For reader 1, the post-CRT ADC and the ΔADC presented the higher AUC (0.823 and 0.803, respectively), while Δ%ADC provided the lower AUC value (0.682). The optimal cutoff point was 1.294 s/mm(2) for post-CRT measures (sensitivity=86.4%, specificity=66.7%, PPV=86.4%, NPV=66.7%), 0.500 for ΔADC (sensitivity=81.8%, specificity=66.7%, PPV=85.7%, NPV=60.0%) and 59.3% for Δ%ADC (sensitivity=63.4%, specificity=66.7, PPV=82.4%, NPV=42.9%). Similar results were observed for reader 2, with better performance obtained with the ADC post-CRT (AUC of 0.833) and an optimal cut off of 1.277 × 10(-3)s/mm(2).

CONCLUSION

Post-CRT ADC measurements are reliable and reproducible and may be used as a non-invasive tool to evaluate response to therapy as post-CRT ADC values and ΔADC presented good diagnostic performance to select responder patients.

Total mesorectal excision: a comparison of oncological and functional outcomes between robotic and laparoscopic surgery for rectal cancer

BACKGROUND

Long-term data from the CLASICC study demonstrated the oncologic equivalence of laparoscopic and open rectal cancer surgery despite an increased circumferential resection margin involvement in the laparoscopic group in the initial report. Moreover, laparoscopic total mesorectal excision (TME) may be associated with increased rates of male sexual dysfunction compared to conventional open TME. Robotic surgery could potentially obtain better results than laparoscopy. The aim of this study was to compare the clinical and functional outcomes of robotic and laparoscopic surgery in a single-center experience.

METHODS

This study was based on 100 patients who underwent minimally invasive anterior rectal resection with TME. Fifty consecutive robotic rectal anterior resections with TME (R-TME) were compared to the first 50 consecutive laparoscopic rectal resections with TME (L-TME).

RESULTS

Median operative time was 270 min in R-TME and 275 min in L-TME. No conversions occurred in the R-TME group whereas six conversions occurred in the L-TME group. The mean number of harvested lymph nodes was 16.5 ± 7.1 for R-TME and 13.8 ± 6.7 for L-TME. The circumferential margin (CRM) was <2 mm in six L-TME patients, whereas no one in R-TME group had a CRM <2 mm. The International Prostate Symptom Score (IPSS) scores were significantly increased 1 month after surgery in both the L-TME and R-TME groups, but they normalized 1 year after surgery. Erectile function worsened significantly 1 month after surgery in both the groups but it was restored completely 1 year after surgery in the R-TME group and partially in the L-TME group.

CONCLUSIONS

Robotic TME is oncologically safe and adequate for rectal cancer treatment, showing better results than laparoscopic TME in terms of CRM, conversions, and hospital length of stay. Better recovery in voiding and sexual function is achieved with the robotic technique.

Update of exocrine functional diagnostics in chronic pancreatitis

Diagnostics of pancreatic insufficiency rely mainly on tests of pancreatic exocrine function based on either measurement of pancreatic secretion or the secondary effects resulting from lack of digestive enzymes or imaging modalities. These methods have been developing rapidly over the last decades, and the aims of this review were to describe exocrine functional testing and imaging of the pancreas in chronic pancreatitis..

Protective effects of the fermented milk Kefir on X-ray irradiation-induced intestinal damage in B6C3F1 mice

Gastrointestinal damage associated with radiation therapy is currently an inevitable outcome. The protective effect of Kefir was assessed for its usefulness against radiation-induced gastrointestinal damage. A Kefir supernatant was diluted by 2- or 10-fold and administered for 1 week prior to 8 Gray (Gy) X-ray irradiation at a dose rate of 2 Gy/min, with an additional 15 d of administration post-irradiation. The survival rate of control mice with normal drinking water dropped to 70% on days 4 through 9 post-irradiation. On the other hand, 100% of mice in the 10- and 2-fold-diluted Kefir groups survived up to day 9 post-irradiation (p<0.05 and p<0.01, respectively). Examinations for crypt regeneration against 8, 10 and 12 Gy irradiation at a dose rate of 4 Gy/min revealed that the crypt number was significantly increased in the mice administered both diluted Kefir solutions (p<0.01 for each). Histological and immunohistochemical examinations revealed that the diluted Kefir solutions protected the crypts from radiation, and promoted crypt regeneration. In addition, lyophilized Kefir powder was found to significantly recover the testis weights (p<0.05), but had no effects on the body and spleen weights, after 8 Gy irradiation. These findings suggest that Kefir could be a promising candidate as a radiation-protective agent.

A new case of TEMPI syndrome

We present an interesting case of a woman with new onset hypertension and abdominal fullness who was found to have huge bilateral perinephric fluid collections. Extensive workup revealed that she had secondary polycythemia, extensive truncal and proximal extremities telangiectasia and IgA-lambda monoclonal gammopathy of underdetermined significance. We believe that this is one of the rare cases consistent with the recently described TEMPI syndrome.

Differentiation of an intrapancreatic accessory spleen from a small (<3-cm) solid pancreatic tumor: value of diffusion-weighted MR imaging

PURPOSE

To evaluate the value of diffusion-weighted (DW) imaging in differentiation of an intrapancreatic accessory spleen (IPAS) from a small (<3 cm) solid pancreatic tumor.

MATERIALS AND METHODS

This retrospective study was approved by the institutional review board, and informed consent was waived. Twenty patients with IPAS and 22 patients with small solid pancreatic tumors were included. All patients underwent abdominal magnetic resonance (MR) imaging with DW and gadoxetic acid-enhanced imaging. Qualitative (signal intensity) and quantitative (signal intensity and apparent diffusion coefficient [ADC]) evaluations were performed by two observers. Fisher exact test and Mann-Whitney U test were used for comparing groups.

RESULTS

Compared with the spleen, the IPAS showed isointensity more frequently than did small pancreatic tumors on T2-weighted images (95% [19 of 20] vs 41% [nine of 22]), arterial phase images (100% [20 of 20] vs 18% [four of 22]), portal phase images (100% [20 of 20] vs 23% [five of 22]), late phase images (100% [20 of 20] vs 41% [nine of 22]), and DW images with b value of 0 sec/mm(2) (100% [20 of 20] vs 9% [two of 22]), b value of 100 sec/mm(2) (95% [19 of 20] vs 27% [six of 22]), and b value of 800 sec/mm(2) (100% [20 of 20] vs 27% [six of 22]), with significant differences (P < .01). The means of the absolute value of relative signal intensity and ADC ratio on DW images of IPAS were significantly lower and closer to zero than those of pancreatic tumors (P < .05). Visual assessment of the similarity between pancreatic lesion and spleen on DW images for diagnosis of IPAS yielded diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of 95% (40 of 42), 100% (20 of 20), 91% (20 of 22), 91% (20 of 22), and 100% (20 of 20), respectively, for observer 1 and 90% (38 of 42), 95% (19 of 20), 86% (19 of 22), 86% (19 of 22), and 95% (19of 20), respectively, for observer 2.

CONCLUSION

In addition to conventional morphologic MR imaging, DW imaging can be used as a tool for differentiating IPAS from solid pancreatic tumors.

SUPPLEMENTAL MATERIAL

http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12112765/-/DC1.

Diffusion-weighted imaging of the healthy pancreas: ADC values are age and gender dependent

PURPOSE

To investigate the healthy pancreas with diffusion-weighted imaging (DWI) for characterization of age and gender-related differences in apparent diffusion coefficient (ADC) values.

MATERIALS AND METHODS

Sixty six volunteers were prospectively enrolled (33 male, 33 female; range 1.4 to 83.7 years of age) and echo-planar DWI of the pancreas was performed. ADC values were measured in the pancreas head, body, and tail using a pixel-by-pixel approach. Effects of age and gender on ADC values were analyzed using a two-factorial multivariate analysis of variance (MANOVA).

RESULTS

ADC values correlated inversely with the age of the volunteers. The mean global pancreatic ADC values (× 10(-3) mm(2)/s) in the age groups 0-20 years, 21-40 years, and > 40 years were 1.18 ± 0.19, 1.07 ± 0.13, and 0.99 ± 0.18, respectively. Female individuals had higher mean global ADC values than male (1.13 ± 0.14 versus 1.02 ± 0.18 × 10(-3) mm(2)/s). MANOVA showed significant effects of age (P value 0.022, eta(2) = 0.13) and gender (P value 0.001, eta(2) = 0.28) on ADC values.

CONCLUSION

Pancreatic ADC values decline with ageing and show significant gender differences with higher mean values in females. The awareness of baseline values adjusted to age and gender will be important for correct interpretation of individual cases and design of future studies.

Chemical shift MR imaging methods for the quantification of transcatheter lipiodol delivery to the liver: preclinical feasibility studies in a rodent model

PURPOSE

To demonstrate the feasibility of using chemical shift magnetic resonance (MR) imaging fat-water separation methods for quantitative estimation of transcatheter lipiodol delivery to liver tissues.

MATERIALS AND METHODS

Studies were performed in accordance with institutional Animal Care and Use Committee guidelines. Proton nuclear MR spectroscopy was first performed to identify lipiodol spectral peaks and relative amplitudes. Next, phantoms were constructed with increasing lipiodol-water volume fractions. A multiecho chemical shift-based fat-water separation method was used to quantify lipiodol concentration within each phantom. Six rats served as controls; 18 rats underwent catheterization with digital subtraction angiography guidance for intraportal infusion of a 15%, 30%, or 50% by volume lipiodol-saline mixture. MR imaging measurements were used to quantify lipiodol delivery to each rat liver. Lipiodol concentration maps were reconstructed by using both single-peak and multipeak chemical shift models. Intraclass and Spearman correlation coefficients were calculated for statistical comparison of MR imaging-based lipiodol concentration and volume measurements to reference standards (known lipiodol phantom compositions and the infused lipiodol dose during rat studies).

RESULTS

Both single-peak and multipeak measurements were well correlated to phantom lipiodol concentrations (r(2) > 0.99). Lipiodol volume measurements were progressively and significantly higher when comparing between animals receiving different doses (P < .05 for each comparison). MR imaging-based lipiodol volume measurements strongly correlated with infused dose (intraclass correlation coefficients > 0.93, P < .001) with both single- and multipeak approaches.

CONCLUSION

Chemical shift MR imaging fat-water separation methods can be used for quantitative measurements of lipiodol delivery to liver tissues.

A different immunologic profile characterizes patients with HER-2-overexpressing and HER-2-negative locally advanced breast cancer: implications for immune-based therapies

Introduction

The clinical efficacy of trastuzumab and taxanes is at least partly related to their ability to mediate or promote antitumor immune responses. On these grounds, a careful analysis of basal immune profile may be capital to dissect the heterogeneity of clinical responses to these drugs in patients with locally advanced breast cancer undergoing neoadjuvant chemotherapy.

Methods

Blood samples were collected from 61 locally advanced breast cancers (36 HER2^- and 25 HER2⁺) at diagnosis and from 23 healthy women. Immunophenotypic profiling of circulating and intratumor immune cells, including regulatory T (Treg) cells, was assessed by flow cytometry and immunohistochemistry, respectively. Serum levels of 10 different cytokines were assessed by multiplex immunoassays. CD8⁺ T cell responses to multiple tumor-associated antigens (TAA) were evaluated by IFN-γ-enzyme-linked immunosorbent spot (ELISPOT). The Student's t test for two tailed distributions and the Wilcoxon two-sample test were used for the statistical analysis of the data.

Results

The proportion of circulating immune effectors was similar in HER2⁺ patients and healthy donors, whereas higher percentages of natural killer and Treg cells and a lower CD4⁺/CD8⁺ T cell ratio (with a prevalence of naïve and central memory CD8⁺ T cells) were observed in HER2^- cases. Higher numbers of circulating CD8⁺ T cells specific for several HLA-A*0201-restricted TAA-derived peptides were observed in HER2⁺ cases, together with a higher prevalence of intratumor CD8⁺ T cells. Serum cytokine profile of HER2⁺ patients was similar to that of controls, whereas HER2^- cases showed significantly lower cytokine amounts compared to healthy women (IL-2, IL-8, IL-6) and HER2⁺ cases (IL-2, IL-1β, IL-8, IL-6, IL-10).

Conclusions

Compared to HER2- cases, patients with HER2-overexpressing locally advanced breast cancer show a more limited tumor-related immune suppression. This may account for the clinical benefit achieved in this subset of patients with the use of drugs acting through, but also promoting, immune-mediated effects.

Marginal resection for osteosarcoma with effective preoperative chemotherapy

OBJECTIVE

To present the clinical results of marginal resection with effective preoperative chemotherapy for treatment of osteosarcoma.

METHODS

Thirty-eight patients (20 male and 18 female, average age 17 years), underwent marginal resection after confirmation of effective preoperative chemotherapy between 1999 and 2008 and the results were analyzed retrospectively. The distal femur was involved in 22 cases, proximal tibia in 11, proximal humerus in 4, and proximal fibula in 1. Thirty-seven patients were stage IIB and one IIIB. Twenty-nine patients were treated with the DIA, and 9 with the MMIA protocol. Twenty-one patients underwent tumor resection and bone allograft transplantation. The epiphysis was preserved in 9 patients, and not in the other 12. Eleven patients underwent tumor resection and prosthetic replacement, and 4 tumor resection with autograft implantation. One patient underwent tumor resection and allograft with preservation of the epiphysis; another underwent marginal tumor resection only.

RESULTS

All patients received effective preoperative chemotherapy. At a median follow-up of 52 months, local recurrence had developed in one patient (2.6% local recurrence rate). Pulmonary metastases developed in 9 patients (23.7%). Five patients died of metastases, one died of intracranial hemorrhage due to thrombocytopenia caused by postoperative chemotherapy. The overall 2-year survival rate was 87.3%, and event-free survival rate 75.5%. The overall 5-year survival rate was 74.7%, and event-free survival rate 60.8%. Excellent to good function of affected limbs was achieved in 60.5%.

CONCLUSIONS

With careful preoperative evaluation and effective preoperative chemotherapy marginal resection of osteosarcoma can produce good results. Marginal resection of osteosarcoma should be performed by an experienced surgeon who is familiar with the limb salvage rules for osteosarcoma.

The impact of practice environment on laparoscopic colectomy utilization following colorectal residency: a survey of the ASCRS Young Surgeons

AIM

It is often thought that practice patterns are different in private (PP) vs university hospital (UH) settings. We aimed to describe the impact of practice environment on the type of laparoscopic colectomy procedures performed by graduating colorectal surgeons.

METHOD

A review was carried out of prospectively gathered self-reported questionnaire data. Graduates of American Society of Colon and Rectal Surgeons' (ASCRS)-approved colorectal residencies from 2004 to 2008 underwent an on-line survey, developed by the ASCRS Young Surgeons' Committee.

RESULTS

About 177 (52%) of 342 graduates surveyed responded. Practice setting data were available for 157 (89%) surgeons. Gender, geographical location and age were similar in both cohorts. PP surgeons utilized a laparoscopic approach more often for rectal cancer (37% vs 19%; P=0.003). There was no significant difference in the rate of laparoscopic surgery in colon cancer, diverticular disease, inflammatory bowel disease, Clostridium difficile or emergency surgery. PP surgeons operated more often with a partner (43% vs 8%) or surgical assistant (13% vs 4%; both P<0.001), while UH surgeons had a colorectal resident (10% vs 21%) or general surgery resident (15% vs 55%; both P<0.001). Impediments to performing laparoscopic surgery for PP surgeons included a perceived lack of hospital equipment (33% vs 20%) and support (29% vs 17%; both P<0.05). Perception of personal experience, access to trained assistants, financial reimbursement, length of surgery and patient availability were equivalent in both groups.

CONCLUSION

While differences such as type of assistant and impediments to laparoscopic utilization exist between PP- and UH-based practices, early laparoscopic practice patterns remain similar. PP surgeons more frequently perform laparoscopic resection for rectal cancer and with hand-assistance. Despite differences, newly trained colorectal surgeons in both settings utilize and require laparoscopic skills.

Multimarker Analysis of Circulating Tumor Cells in Peripheral Blood of Metastatic Breast Cancer Patients: A Step Forward in Personalized Medicine

AIM: To develop an immunomagnetic assay for the isolation of circulating tumor cells (CTCs) followed by the analysis of a multimarker panel, which will enable the characterization of these malignant cells with high accuracy. PATIENTS AND METHODS: Peripheral blood (PB) was collected from 32 metastatic breast cancer patients and 42 negative controls. The antibodies BM7 and VU1D9 were used for immunomagnetic tumor cell enrichment. A real-time reverse transcription-polymerase chain reaction (RT-PCR) approach for the markers KRT19, SCGB2A2, MUC1, EPCAM, BIRC5 and ERBB2 was used for CTC detection and characterization. RESULTS: THE POSITIVITY RATES FOR EACH MARKER WERE AS FOLLOWS: 46.9% for KRT19, 25.0% for SCGB2A2, 28.1% for MUC1, 28.1% for EPCAM, 21.9% for BIRC5, and 15.6% for ERBB2. After the creation of individualized cutoffs, the sensitivity and specificity of the combined marker gene panel increased to 56.3% and 100%, respectively. Interestingly, 27.0% of the HER2-negative tumor patients showed ERBB2 mRNA-positive CTCs. CONCLUSIONS: The described technique can be used to measure CTCs with great accuracy. The use of a multimarker panel for the characterization of CTCs may provide real-time information and be of great value in therapy monitoring.

Factors influencing the quality of total mesorectal excision

BACKGROUND

Total mesorectal excision (TME) has become the standard of care for rectal cancer. Incomplete TME may lead to local recurrence.

METHODS

Data from the multicentre observational German Quality Assurance in Rectal Cancer Trial were used. Patients undergoing low anterior resection for rectal cancer between 1 January 2005 and 31 December 2009 were included. Multivariable analysis using a stepwise logistic regression model was performed to identify predictors of suboptimal TME.

RESULTS

From a total of 6179 patients, complete data sets for 4606 patients were available for analysis. Pathological tumour category higher than T2 (pT3 versus pT1/2: odds ratio (OR) 1.22, 95 per cent confidence interval 1.01 to 1.47), tumour distance from the anal verge less than 8 cm (OR 1.27, 1.05 to 1.53), advanced age (65-80 years: OR 1.25, 1.03 to 1.52; over 80 years: OR 1.60, 1.15 to 2.22), presence of intraoperative complications (OR 1.63, 1.15 to 2.30), monopolar dissection technique (OR 1.43, 1.14 to 1.79) and low case volume (fewer than 20 procedures per year) of the operating surgeon (OR 1.20, 1.06 to 1.36) were independently associated with moderate or poor TME quality.

CONCLUSION

TME quality was influenced by patient- and treatment-related factors.

Intraperitoneal chemotherapy for recurrent epithelial ovarian cancer is feasible with high completion rates, low complications, and acceptable patient outcomes

OBJECTIVES

Three large randomized clinical trials have shown a survival benefit for patients treated with intraperitoneal (IP) compared with intravenous chemotherapy for advanced stage epithelial ovarian cancer (EOC). However, the use of IP chemotherapy in recurrent EOC is controversial. The purpose of this study was to determine outcomes, completion rates, and frequency of complications in patients with platinum-sensitive recurrent EOC treated with IP chemotherapy.

METHODS

A retrospective, single-institution analysis of women who received IP chemotherapy for recurrent EOC from January 2003 to April 2010 was conducted. Study patients were identified from the Tumor Registry and office records. Demographic factors, stage, histology, surgical findings, cytoreduction status, and subsequent therapies were abstracted. Progression-free (PFS) and overall survival (OS) were estimated by Kaplan-Meier methods.

RESULTS

Fifty-six women who received IP chemotherapy for their first EOC recurrence were identified. The mean age of patients was 56.7 years (range, 40-79 y). Fifty-five patients (98.3%) had previously completed at least 6 cycles of intravenous chemotherapy. Of all patients, 87.5% were initially diagnosed with advanced stage disease (stage IIA-IV). All patients underwent secondary cytoreduction at the time of IP port placement. Moreover, 67.9% of patients were considered optimally cytoreduced (<1 cm residual disease) at the end of the secondary debulking surgery. Forty-two patients (75%) were able to successfully complete at least 6 cycles of IP chemotherapy. Reasons for noncompletion were disease progression, allergic reaction, renal failure, pain, severe nausea and vomiting, death, and patient refusal. Six patients (10.7%) developed port complications including pain around port site, port malfunction, and port erosion into small bowel. Median PFS since the initiation of IP chemotherapy was 10.5 months (95% confidence interval, 7.5-16.4 months) and median OS was 51 months (95% confidence interval, 40.8-61.1 months).

CONCLUSIONS

Intraperitoneal chemotherapy is a feasible option for patients with recurrent EOC, with high completion rates, low frequency of complications, and acceptable PFS and OS.

Comprehensive analysis of published phase I/II clinical trials between 1990-2010 in osteosarcoma and Ewing sarcoma confirms limited outcomes and need for translational investment

Background

High grade primary bone sarcomas are rare cancers that affect mostly children and young adults. Osteosarcoma and Ewing sarcoma are the most common histological subtypes in this age group, with current multimodality treatment strategies achieving 55-70% overall survival. As there remains an urgent need to develop new therapeutic interventions, we have reviewed published phase I/II trials that have been reported for osteosarcoma and Ewing sarcoma in the last twenty years.

Results

We conducted a literature search for clinical trials between 1990 and 2010, either for trials enrolling bone sarcoma patients as part of a general sarcoma indication or trials specifically in osteosarcoma and Ewing sarcoma. We identified 42 clinical trials that fulfilled our search criteria for general sarcoma that enrolled these patient groups, and eight and twenty specific trials for Ewing and osteosarcoma patients, respectively. For the phase I trials which enrolled different tumour types our results were incomplete, because the sarcoma patients were not mentioned in the PubMed abstract. A total of 3,736 sarcoma patients were included in these trials over this period, 1,114 for osteosarcoma and 1,263 for Ewing sarcoma. As a proportion of the worldwide disease burden over this period, these numbers reflect a very small percentage of the potential patient recruitment, approximately 0.6% for Ewing sarcoma and 0.2% for osteosarcoma. However, these data show an increase in recent activity overall and suggest there is still much room for improvement in the current trial development structures.

Conclusion

Lack of resources and commercial investment will inevitably limit opportunity to develop sufficiently rapid improvements in clinical outcomes. International collaboration exists in many well founded co-operative groups for phase III trials, but progress may be more effective if there were also more investment of molecular and translational research into disease focused phase I/II clinical trials. Examples of new models for early translational and early phase trial collaboration include the European based EuroBoNeT network, the Sarcoma Alliance for Research through Collaboration network (SARC) and the new European collaborative translational trial network, EuroSarc.

The role of pancreatic imaging in monogenic diabetes mellitus

In neonatal diabetes mellitus resulting from mutations in EIF2AK3, PTF1A, HNF1B, PDX1 or RFX6, pancreatic aplasia or hypoplasia is typical. In maturity-onset diabetes mellitus of the young (MODY), mutations in HNF1B result in aplasia of pancreatic body and tail, and mutations in CEL lead to lipomatosis. The pancreas is not readily accessible for histopathological investigations and pancreatic imaging might, therefore, prove important for diagnosis, treatment, and research into these β-cell diseases. Advanced imaging techniques can identify the pancreatic features that are characteristic of inherited diabetes subtypes, including alterations in organ size (diffuse atrophy and complete or partial pancreatic agenesis), lipomatosis and calcifications. Consequently, in patients with suspected monogenic diabetes mellitus, the results of pancreatic imaging could help guide the molecular and genetic investigation. Imaging findings also highlight the critical roles of specific genes in normal pancreatic development and differentiation and provide new insight into alterations in pancreatic structure that are relevant for β-cell disease.

P-glycoprotein binds to ezrin at amino acid residues 149-242 in the FERM domain and plays a key role in the multidrug resistance of human osteosarcoma

Overexpression of the mdr1 gene encoding P-glycoprotein (Pgp) exerts a major role in reducing the effectiveness of cytotoxic therapy in osteosarcoma. The interaction between actin and Pgp has been shown to be instrumental in the establishment of multidrug resistance (MDR) in human tumor cells. The cytoskeleton linker ezrin exerts a pivotal role in maintaining the functional connection between actin and Pgp. We investigated the role of ezrin in a human multidrug-resistant osteosarcoma cell line overexpressing Pgp and compared it to its counterpart that overexpresses an ezrin deletion mutant. The results showed that Pgp binds at amino acid residues 149-242 of the N-terminal domain of ezrin. The interaction between ezrin and Pgp occurs in the plasma membrane of MDR cells, where they also co-localize with the ganglioside G(M1) located in lipid rafts. The overexpression of the ezrin deletion mutant entirely restored drug susceptibility of osteosarcoma cells, consistent with Pgp dislocation to cytoplasmic compartments and abrogation of G(M1) /Pgp co-localization at the plasma membrane. Our study provides evidence that ezrin exerts a key role in MDR of human osteosarcoma cells through a Pgp-ezrin-actin connection that is instrumental for the permanence of Pgp into plasma membrane lipid rafts. We also show for the first time that Pgp-binding site is localized to amino acid residues 149-242 of the ezrin Band 4.1, Ezrin/Radixin/Moesin (FERM) domain, thus proposing a specific target for future molecular therapy aimed at counteracting MDR in osteosarcoma patients.

Cytokeratin-19 and mammaglobin gene expression in circulating tumor cells from metastatic breast cancer patients enrolled in North Central Cancer Treatment Group trials, N0234/336/436/437

PURPOSE

To investigate the associations between baseline and posttreatment circulating tumor cell (CTC) gene expression and outcome of patients enrolled in four North Central Cancer Treatment Group metastatic breast cancer (MBC) trials in which specimens were shipped (at 4°C) from community-based sites to a reference laboratory (Mayo Clinic, Rochester, MN).

EXPERIMENTAL DESIGN

Blood was collected at treating sites from MBC patients before (baseline), during, and at the end of treatment with erlotinib + gemcitabine (N0234), sorafenib (N0336), irinotecan + cetuximab (N0436), or paclitaxel-poliglumex + capecitabine (N0437). CTCs from 10 mL of EDTA blood were enriched with CD45 depletion, 24 to 30 hours postblood collection. Reverse transcription/quantitative PCR was used to determine cytokeratin-19 (CK19) and mammaglobin (MGB1) mRNA levels in CTCs from up to 13 (N0234), 16 (N0336), 18 (N0436), and 39 (N0437) patients. The gene expressions were normalized to β(2)-microglobulin and calibrated to healthy blood using the 2(-ΔΔCq) algorithm; positivity was defined as 2 or more.

RESULTS

CK19+mRNA cells were detected in 56% to 75% and MGB1+mRNA cells in 23% to 38% of 86 patients at baseline. CK19+mRNA cells were detected in 30% to 67% and MGB1+mRNA cells in 14% to 64% of 110 postbaseline serial samples. The presence of baseline CK19+mRNA cells (P = 0.01) but not MGB1+mRNA cells (P = 0.14) was significantly associated with shorter overall survival. A decrease in MGB1+mRNA levels (baseline-week 8) seemed to be associated with clinical response (P = 0.05).

CONCLUSIONS

CTC gene expression analysis conducted by a reference laboratory is feasible when blood is collected from treating sites and processed 24 to 30 hours postcollection. The presence of baseline CK19+mRNA CTCs was associated with poor prognosis; a decrease in MGB1+mRNA CTCs may help predict response to therapy of MBC patients.

Human mammaglobin: a superior marker for reverse-transcriptase PCR in detecting circulating tumor cells in breast cancer patients

Breast cancer is the most frequent cancer in women in the USA and the second most common cause of death in females who develop cancer. Recently, the detection of circulating tumor cells has emerged as a promising tool for monitoring the progression of clinically occult micrometastases in breast cancer patients. Sensitive molecular techniques, primarily based upon the reverse-transcriptase PCR, using various molecules as markers, have been developed to detect circulating tumor cells. Among those molecules, human mammaglobin mRNA has been found to be the most specific marker for the hematogenous spread of breast cancer cells. In this article, we review the current knowledge regarding the use of reverse-transcriptase PCR for detecting human mammaglobin mRNA as a biomarker for circulating tumor cells in breast cancer patients, and evaluate the clinical implications of human mammaglobin since it was first isolated in 1996.

Usefulness of diffusion-weighted imaging of breast tumors: quantitative and visual assessment

PURPOSE

We evaluated the usefulness of quantitative and visual assessment of diffusion-weighted imaging (DWI) of breast tumors to distinguish malignant from benign tumors.

MATERIALS AND METHODS

The DWI findings of 106 breast lesions (15 benign, 91 malignant) were retrospectively analyzed. The mean apparent diffusion coefficient (ADC) value for each lesion was calculated using b values of 250, 500, 750, and 1000 s/mm(2) as a quantitative assessment. We visually evaluated the signal intensity of each breast lesion on the basis of a spinal signal intensity in DWI (b = 1000 s/mm(2)) and compared the mean ADC values using a threshold mean ADC +1.65 × standard deviation (SD) for malignant and benign breast lesions. Obviously strong signal intensity of the lesion relative to that of the spinal cord on DWI signifies malignancy.

RESULTS

The mean ADC value for benign lesions (1.50 ± 0.38 × 10(-3) mm(2)/s) was significantly higher than that for malignant lesions (0.98 ± 0.19 × 10(-3) mm(2)/s), with 94.5% sensitivity, 80% specificity, and 92.5% accuracy. Sensitivity for visual assessment was 91.5%, specificity was 33.3%, and total accuracy was 82.5%.

CONCLUSION

ADC values, but not visual assessment, may be useful for differentiating benign and malignant breast tumors.

Diffusion-weighted magnetic resonance imaging in the upper abdomen: technical issues and clinical applications

Recent technological achievements have enabled the transposition of diffusion-weighted imaging (DWI) with good diagnostic quality into other body regions, especially the abdomen and pelvis. Many emerging and established applications are now being evaluated on the upper abdomen, the liver being the most studied organ. This article discusses imaging strategies for DWI on the upper abdomen, describes the clinical protocol, and reviews the most common clinical applications of DWI on solid abdominal organs.

Chronic pancreatitis

Chronic pancreatitis is a progressive fibroinflammatory disease that exists in large-duct (often with intraductal calculi) or small-duct form. In many patients this disease results from a complex mix of environmental (eg, alcohol, cigarettes, and occupational chemicals) and genetic factors (eg, mutation in a trypsin-controlling gene or the cystic fibrosis transmembrane conductance regulator); a few patients have hereditary or autoimmune disease. Pain in the form of recurrent attacks of pancreatitis (representing paralysis of apical exocytosis in acinar cells) or constant and disabling pain is usually the main symptom. Management of the pain is mainly empirical, involving potent analgesics, duct drainage by endoscopic or surgical means, and partial or total pancreatectomy. However, steroids rapidly reduce symptoms in patients with autoimmune pancreatitis, and micronutrient therapy to correct electrophilic stress is emerging as a promising treatment in the other patients. Steatorrhoea, diabetes, local complications, and psychosocial issues associated with the disease are additional therapeutic challenges.

Enhancing pancreatic adenocarcinoma delineation in diffusion derived intravoxel incoherent motion f-maps through automatic vessel and duct segmentation

Diffusion-based intravoxel incoherent motion imaging has recently gained interest as a method to detect and characterize pancreatic lesions, especially as it could provide a radiation- and contrast agent-free alternative to existing diagnostic methods. However, tumor delineation on intravoxel incoherent motion-derived parameter maps is impeded by poor lesion-to-pancreatic duct contrast in the f-maps and poor lesion-to-vessel contrast in the D-maps. The distribution of the diffusion and perfusion parameters within vessels, ducts, and tumors were extracted from a group of 42 patients with pancreatic adenocarcinoma. Clearly separable combinations of f and D were observed, and receiver operating characteristic analysis was used to determine the optimal cutoff values for an automated segmentation of vessels and ducts to improve lesion detection and delineation on the individual intravoxel incoherent motion-derived maps. Receiver operating characteristic analysis identified f = 0.28 as the cutoff for vessels (Area under the curve (AUC) = 0.901) versus tumor/duct and D = 1.85 μm(2) /ms for separating duct from tumor tissue (AUC = 0.988). These values were incorporated in an automatic segmentation algorithm and then applied to 42 patients. This yielded clearly improved tumor delineation compared to individual intravoxel incoherent motion-derived maps. Furthermore, previous findings that indicated that the f value in pancreatic cancer is strongly reduced compared to healthy pancreatic tissue were reconfirmed.

Robotic technologies in surgical oncology training and practice

The modern-day surgeon is frequently exposed to new technologies and instrumentation. Robotic surgery (RS) has evolved as a minimally invasive technique aimed to improve clinical outcomes. RS has the potential to alleviate the inherent limitations of laparoscopic surgery such as two dimensional imaging, limited instrument movement and intrinsic human tremor. Since the first reported robot-assisted surgical procedure performed in 1985, the technology has dramatically evolved and currently multiple surgical specialties have incorporated RS into their daily clinical armamentarium. With this exponential growth, it should not come as a surprise the ever growing requirement for surgeons trained in RS as well as the interest from residents to receive robotic exposure during their training. For this reason, the establishment of set criteria for adequate and standardized training and credentialing of surgical residents, fellows and those trained surgeons wishing to perform RS has become a priority. In this rapidly evolving field, we herein review the past, present and future of robotic technologies and its penetration into different surgical specialties.

Ifosfamide metabolite chloroacetaldehyde inhibits cell proliferation and glucose metabolism without decreasing cellular ATP content in human breast cancer cells MCF-7

Chloroacetaldehyde (CAA), a product of hepatic metabolism of the widely used anticancer drug ifosfamide (IFO), has been reported to decrease cancer cell proliferation. The basis of this effect is not completely known but has been attributed to a drop of cellular ATP content. Given the importance of glucose metabolism and of the 'Warburg effect' in cancer cells, we examined in the present study the ability of CAA to inhibit cancer cell proliferation by altering the glycolytic pathway. Cell proliferation, ATP content, glucose transport and metabolism as well as the activities of the main enzymes of glycolysis were determined in human breast cancer cells MCF-7 in the presence of various CAA concentrations (5-50 microm). Our results show that low CAA concentrations inhibited cell proliferation in a concentration-dependent manner. This inhibition was explained by a decrease in glucose utilization. Cellular ATP content was not reduced but even increased with 25 microm CAA. The inhibition of glucose metabolism was mainly explained by the decrease in glucose transport and hexokinase activity. The activity of glyceraldehyde-3-phosphate dehydrogenase, but not that of phosphofructokinase, was also inhibited. Glycolysis inhibition by CAA was effective in decreasing the proliferation of MCF-7 cells. Interestingly, this decrease was not due to ATP depletion; rather, it was linked to a drop of biosynthetic precursors from glycolytic intermediates. This CAA-induced inhibition of cell proliferation suggests that it might play a role in the antitumor activity of IFO.

Abdominal magnetic resonance imaging at 3 T: oncological applications

The gain in signal-to-noise ratio at 3 T magnetic resonance (MR) imaging produces many benefits for abdominal imaging applications, including the capability to reduce acquisition times and/or improve spatial resolution for a variety of pulse sequences, the potential for broader application of parallel imaging techniques, and an increased sensitivity to gadolinium-based contrast media. These advances have the potential of improving the accuracy of MR imaging in the detection, staging, treatment planning, and follow-up of patients with abdominal tumors. At the same time, because certain high-field-strength-related drawbacks could not be compensated for, abdominal 3 T MR imaging should be clinically implemented with caution in some patients (eg, patients with massive ascites).

[The development of the first line treatment of metastatic colorectal cancer (mCRC)]

Chemotherapy options of metastatic colorectal cancer (mCRC) have been progressed rapidly in the last years. Besides of the standard fluorouracil/folinic acid treatment some new active agents (oxaliplatin and irinotecan) have been introduced, and more recently the "targeted" biologicals (bevacizumab, cetuximab, panitumumab) have demonstrated their high effectiveness. This review summarizes the development of the first line treatment of mCRC.

Targets of chloroacetaldehyde-induced nephrotoxicity

Chloroacetaldehyde, one of the main products of hepatic ifosfamide metabolism, contributes to its nephrotoxicity. However, the pathophysiology of this toxicity is not fully understood. The present work examined the time and dose effects of clinically relevant concentrations of chloroacetaldehyde (25-75microM) on precision-cut rat renal cortical slices metabolizing a physiological concentration of lactate. Chloroacetaldehyde toxicity was demonstrated by the decrease in total glutathione and cellular ATP levels. The drop of cellular ATP was linked to the inhibition of oxidative phosphorylation at the level of complex I of the mitochondrial respiratory chain. The large decrease in glucose synthesis from lactate was explained by the inhibition of some gluconeogenic enzymes, mainly glyceraldehyde 3-phosphate dehydrogenase. The decrease in lactate utilization was demonstrated not only by a defect of gluconeogenesis but also by the decrease in [(14)CO(2)] formation from [U-(14)C]-lactate. All the effects of chloroacetaldehyde were concentration and time-dependent. Finally, the chloroacetaldehyde-induced inhibition of glyceraldehyde 3-phosphate dehydrogenase, which is also a glycolytic enzyme, suggests that, under conditions close to those found during ifosfamide therapy, the inhibition of glycolytic pathway by chloroacetaldehyde might be responsible, at least in part, for the therapeutic efficacy of ifosfamide.

A review of the current evidence for maintenance therapy in ovarian cancer

OBJECTIVES

Ovarian cancer (OC) typically is diagnosed at advanced stages, in which the primary goal of therapy is to prolong progression-free survival (PFS) and overall survival (OS). In recent years, maintenance therapy has been tested for this purpose in advanced OC (AOC). Literature on maintenance therapy in AOC was systematically reviewed to assess current knowledge regarding the impact of this therapeutic approach.

METHODS

A MEDLINE search was performed 2/2009 for articles published 1/2001-1/2009 pertaining to OC maintenance therapy guidelines, patterns, and outcomes. A second search used keywords specific to maintenance and included primary studies published in the last 10 years. Of 406 sources identified, 36 primary studies and 16 review articles were included in this systematic review. A third search used the keyword "consolidation" to find maintenance articles not identified through other searches; of 48 additional sources, 13 primary studies and 6 reviews were included. A fourth search of non-MEDLINE-indexed sources yielded 14 additional relevant publications from the same time period.

RESULTS

Among practice guidelines identified, only the National Comprehensive Cancer Network (NCCN) 2008 guidelines provide recommendations regarding maintenance therapy, assigning it a category 2B recommendation. No studies were identified that reported current treatment patterns or economic outcomes in maintenance therapy; quality of life data were reported in one study. A variety of agents have been tested for maintenance, with paclitaxel the most commonly evaluated. The Southwest Oncology Group-Gynecologic Oncology Group 178 trial has found that 12 cycles of paclitaxel extend PFS (by 7 months) compared to 3 months paclitaxel, but could not adequately evaluate OS.

CONCLUSIONS

Maintenance therapy may improve clinical outcomes in AOC, but additional research is needed to demonstrate an OS advantage. Future studies should investigate the long-term clinical benefit of maintenance treatment and its impact on resource utilization and health-related quality of life.

Intra-operative intra-peritoneal chemotherapy with cisplatin in patients with peritoneal carcinomatosis of ovarian cancer

Background

Intra-peritoneal (i.p.) chemotherapy is an encouraging treatment option for ovarian cancer with peritoneum involvement in addition with intravenous (i.v.) chemotherapy. Intra-operative i.p. chemotherapy is an interesting method of administration by enhancing the diffusion of chemotherapy. This study had assessed the feasibility of intra-operative i.p. chemotherapy in patients with peritoneal carcinoma of ovarian cancer.

Methods

From January 2003 to February 2006, 47 patients with stage III ovarian cancer were treated with standard paclitaxel carboplatin intravenous chemotherapy and debulking surgery with intra-operative i.p. chemotherapy. After optimal cytoreductive surgery, defined by no unresectable residual disease > 1 cm, i.p. chemotherapy was performed during surgery. The peritoneal cavity was filled by 3 litres of isotonic saline pre-heated at 37 degrees and 90 mg of cisplatin. The sequence was repeated twice during 2 hours based on previous published studies which optimized the cisplatin dosage and exposure duration. Optimal diffusion was obtained by stirring by hands during the 2 hours.

Results

Median age was 59.6 years. No severe haematological or non-haematological toxicity induced by intra operative i.p. chemotherapy was reported. No patient died due to the complications of surgery or the i.p. chemotherapy. No neurotoxicity occurred, and one patients had renal impairment.

Conclusion

This study demonstrates the feasibility of intra-operative i.p. chemotherapy with cisplatin after optimal resection of peritoneal tumor nodules. Further randomized trials are planned to investigate the clinical benefit of this therapeutic modality.

Intraperitoneal chemotherapy in the management of patients with advanced epithelial ovarian cancer: a critical review of the literature

The use of intraperitoneal (IP) chemotherapy has been advocated in different settings of patients with ovarian cancer. Cisplatin is the drug of choice because of its high response rate and minimal local toxicity. This treatment can be given to women with small residual disease after second look, with surgically assessed complete response rates of approximately 30%, and with a prolonged survival in small subset of patients. However, the use of IP chemotherapy as consolidation treatment of pathologically complete responders after first-line systemic chemotherapy has not been definitively evaluated in a phase III trial. There is much debate in the literature both for and against the use of IP chemotherapy in the first-line treatment of optimally debulked ovarian cancer patients. The recent Cochrane meta-analyses of eight randomized trials enrolling 1819 patients has shown that first-line IP chemotherapy improves progression-free survival and overall survival of patients with minimal residual disease after initial surgery. However, the potential for catheter-related complications, abdominal pain with infusion, and toxicities needs to be taken into consideration for decision making in each individual woman. Rectosigmoidal surgery can be associated with gross contamination of the operative field, and in this case, the catheter placement should not be performed during primary surgery but should be delayed to 3 weeks later. Patients should be provided with information on the survival and toxicity for both IP and systemic treatments, as well as practical information about the administration of each regimen, so that they may be involved in the decision-making process.

Extraperitoneal Leakage as a Possible Explanation for Failure of One-Time Intraperitoneal Treatment in Ovarian Cancer

We conducted a single-arm study to determine the biodistribution of intraperitoneally (i.p.) administered 90yttrium-labeled murine monoclonal antibody HMFG1 (90Y-muHMFG1) in patients with advanced stage ovarian cancer. Seventeen (17) patients in complete clinical remission for epithelial ovarian cancer were included. After completion of chemotherapy, a mixture of 111indium-labeled muHMFG1 (imaging) and 90Y-muHMFG1 (therapy) was i.p. administered by a surgically placed, indwelling i.p. catheter. Planar and single-photon emission computed tomography images were recorded to determine the distribution of the study medication during the first 6 days postinjection. Of the first 3 patients, 2 patients had extraperitoneal leakage of up to 50% of the injected dose within 24 hours after injection of the study medication. Extraperitoneal leakage was mainly seen in the retroperitoneal spaces covering the upper and lower quadrant of the abdomen. After adjustments in the procedure, leakage was observed in 2 of the remaining 14 patients. Extraperitoneal leakage of i.p. administered therapy does occur. Such leakage would reduce the locally delivered dose of a drug and could potentially have a negative impact on therapeutic efficacy. Given the potential attraction of developing i.p. treatments for intra-abdominal cancer, the observations in this study need to be taken into consideration.

Intraperitoneal chemotherapy for advanced epithelial ovarian cancer: A Canadian perspective

The objectives of this study were to: a) assess the position of Canadian gynecological oncologists (GOC) toward intraperitoneal (IP) chemotherapy as primary treatment for ovarian cancer, b) initiate a process of communication among GOC, and c) assess the perception of barriers to implementing IP chemotherapy across Canada. An electronic practice survey was mailed to all GOC in January 2006. The response rate was 62%. GOC accept IP chemotherapy as the standard of care in the primary treatment of optimally debulked epithelial ovarian cancer. The majority of respondents were working on implementation strategies at their local institutions. The cost of administration and use of additional resources were identified as sources of moderate and high concerns, respectively. Moderate concerns were expressed with regard to the management of systemic and local toxicity, catheter complications, patients' acceptance, and quality of life. Catheter insertion issues were of low concern to most respondents. Previous experience with IP administration did not significantly impact the perceived level of concern. GOC support the use of IP chemotherapy for appropriate patients with ovarian cancer. This survey identifies important implementation challenges of IP therapy for Canada, and processes must be developed before successful delivery of IP chemotherapy can be realized. This survey serves to initiate a process of communication among GOC. A collaborative effort will be needed to facilitate this change in practice. Further study of the implementation process is warranted as more experience is gained with this modality of treatment.

Intraperitoneal chemotherapy for ovarian cancer

PURPOSE OF REVIEW

Intraperitoneal chemotherapy for ovarian cancer is based on sound pharmacological principles and is technically feasible. There is mounting evidence, bolstered by a recent randomized trial, that in certain patients, this route of delivery may be superior to traditional intravenous chemotherapy. This review explores the background and pharmacokinetic principles of intraperitoneal chemotherapy, the recent evidence supporting an intraperitoneal approach, and some of the logistical and technical challenges involved.

RECENT FINDINGS

Intraperitoneal chemotherapy has been evaluated in several settings. Most phase I and II data came from second-line treatment of ovarian cancer, and there have been a few series, including one recent phase III trial, exploring intraperitoneal consolidation. The greatest impact among recent studies will be from a large, intergroup phase III trial evaluating intraperitoneal therapy in the front-line setting. This study will probably change the dialogue of standard treatment for optimally cytoreduced, advanced epithelial ovarian cancer.

SUMMARY

Based on recent findings, intraperitoneal chemotherapy should be considered for the front-line treatment of women with minimal residual advanced ovarian cancer. Efforts should continue to facilitate the integration of intraperitoneal treatment into mainstream practice, and future trials should be designed to address lingering controversy surrounding this route of treatment.

Consolidation therapy in ovarian cancer: where do we stand?

PURPOSE OF REVIEW

The goal of consolidation chemotherapy in ovarian cancer is to maximize the benefit of primary therapy and improve progression-free and overall survival. Consolidation has been tested with multiple treatment modalities including cytotoxic chemotherapy, radiation and biological therapies. A review of recently published clinical trials is presented.

RECENT FINDINGS

Consolidation therapy is not a new concept. More than 30 clinical trials utilizing consolidation therapy have been published in the last two decades. The natural history of many patients who participate in consolidation trials is often favorable, making the effect of consolidation treatments difficult to interpret. Small phase II studies have suggested improved outcomes compared with historical controls, but randomized trials have yet to show a distinct survival advantage with consolidation therapy.

SUMMARY

The role of consolidation therapy in ovarian cancer is evolving. Although it is recognized that ovarian cancer patients commonly suffer recurrences after initial response, it is not clear that current therapies alter this course. Future clinical designs should include appropriate control groups. Novel therapies should be studied in randomized controlled trials with sufficient power to detect relevant clinical differences, the most important being overall survival. Toxicity and ease of administration must be considered against the benefits of therapy.

Phase III Trial of Intraperitoneal Therapy With Yttrium-90–Labeled HMFG1 Murine Monoclonal Antibody in Patients With Epithelial Ovarian Cancer After a Surgically Defined Complete Remission

Purpose

This was a multinational, open-label, randomized phase III trial comparing yttrium-90–labeled murine HMFG1 (90Y-muHMFG1) plus standard treatment versus standard treatment alone in patients with epithelial ovarian cancer (EOC) who had attained a complete clinical remission after cytoreductive surgery and platinum-based chemotherapy.

Patients and Methods

In total, 844 International Federation of Gynecology and Obstetrics stage Ic to IV patients were initially screened, of whom 447 patients with a negative second-look laparoscopy (SLL) were randomly assigned to receive either a single dose of 90Y-muHMFG1 plus standard treatment (224 patients) or standard treatment alone (223 patients). Patients in the active treatment arm received a single intraperitoneal dose of 25 mg of 90Y-muHMFG1 (target dose 666 MBq/m2). The primary end point was length of survival; secondary end points included time to relapse and safety. The study had an 80% power to detect a 15% change in survival.

Results

After a median follow-up of 3.5 years (range, 1 to 6 years), 70 patients had died in the active treatment arm compared with 61 patients in the control arm. Cox proportional hazards analysis of survival demonstrated no difference between treatment arms. In the study drug arm, 104 patients experienced relapse compared with 98 patients in the standard treatment arm. No difference in time to relapse was observed between the two study arms. Active therapy was associated with occasional grade 3 or 4 thrombocytopenia and neutropenia and grade 1 or 2 GI symptoms, abdominal discomfort, arthralgia, and myalgia.

Conclusion

A single IP administration of 90Y-muHMFG1 to patients with EOC who had a negative SLL after primary therapy did not extend survival or time to relapse.