Angiogenesis inhibition with bevacizumab and the surgical management of colorectal cancer

Mortality of patients with metastatic colorectal cancer who received elective or emergent operation after exposure to bevacizumab: A nationwide database study

INTRODUCTION

Treatment guidelines for colorectal cancer (CRC) indicate that surgical intervention within 4 weeks or 8 weeks after bevacizumab therapy might increase the risk of postoperative complications and mortality, especially in patients who received emergent operation. Therefore, we aimed to assess the association between different surgical timings, emergent or elective surgery, and the risk of postoperative mortality.

MATERIALS AND METHODS

Using the Taiwan National Health Insurance Database and Taiwan Cancer Registry, we identified patients with metastatic colorectal cancer (mCRC) who underwent surgery within 1 year of receiving bevacizumab between January 2010 and December 2017. The primary outcomes were 30-day, 60-day, and in-hospital mortality; the secondary outcomes were hospital stay, 30-day readmission rate, and surgical complications. Multivariate analysis was used to adjust for confounders.

RESULTS

This study included 2,047 patients. In the multivariate analysis, patients who underwent emergent operation and had higher Charlson scores had a significantly higher mortality rate. Patients with a longer interval to surgery, more cycles of bevacizumab treatment, and distal metastectomy had the opposite result. In subgroup analysis, patients who received emergent operation within 28 days had the highest surgical mortality.

CONCLUSIONS

The interval to operation among mCRC patients who receive bevacizumab treatment should exceed 4 weeks to avoid additional risk of mortality whether patients receiving elective or emergent operation. Patients who received emergent operation within 28 days of bevcizumab infusion had the highest risk of mortality.

Pneumothorax as a Complication of Bevacizumab-Containing Chemotherapy: A Systematic Review of Case Reports

Bevacizumab is a monoclonal anti-vascular endothelial growth factor (VEGF) antibody that binds to and makes all of the VEGF isoforms inactive, and thus prevents angiogenesis, development, and the spread of the tumor. The most reported side effects after administering bevacizumab include bleeding, high blood pressure, heart failure, proteinuria, thrombosis, and gastrointestinal perforation. Pneumothorax has rarely been reported as a complication of bevacizumab, but with an unclear mechanism. This article aims to explore the occurrence of pneumothorax as a side effect after using bevacizumab through a systematic review of current case reports published on the topic. A literature search was conducted using PubMed, Google Scholar, ScienceDirect, and Directory of Open Access through the utilization of appropriate keywords, and case reports were selected based on predefined inclusion and exclusion criteria. Our results encompass five case reports that were further evaluated for demographic, clinical, and treatment parameters. This systematic review concludes that pneumothorax can occur after bevacizumab-containing chemotherapy although this side effect is relatively rare. Awareness regarding this possible side effect can assist clinicians during their practice in considering pneumothorax as a possible differential diagnosis when encountering patients presenting with pulmonary symptoms after starting bevacizumab-containing chemotherapy; hence, timely diagnosis and treatment can save a life.

The Role of Preoperative Platelet-to-Lymphocyte Ratio as a Predictor for Incisional Hernias after Hand-Assisted Laparoscopic Liver Surgery for Metastatic Colorectal Cancer

(1) Background: Hand-assisted laparoscopic surgery for liver resection is a globally established technique. In this study, we report on the incidence and risk factors for postoperative incisional hernia (IH) after hand-assisted laparoscopic surgery for colorectal liver metastasis. (2) Methods: This was retrospective analysis of 89 consecutive hand-assisted laparoscopic surgery for colorectal liver metastasis. (3) Results: Participants were 39 females and 50 males. Median age was 65 years, and in 63%, the BMI was ≥25. Postoperative complications were encountered in 18% of the patients. Seven patients (7.8%) had postoperative incisional hernia in the hand port site. There was significantly higher incidence of incisional hernia in overweight patients (BMI ≥ 25) (p = 0.04), and in cases with simultaneous liver and colon resection (p = 0.02). In univariant and multivariant analyses, simultaneous liver and colon resection (p = 0.004 and 0.03, respectively), and platelet-to-lymphocyte ratio ≤ 200 (p = 0.03, 0.04, respectively) were both independent risk factors for developing postoperative incisional hernia. (4) Conclusions: Both simultaneous liver and colon resection, and platelet-to-lymphocyte ratio ≤ 200 are independent risk factors for postoperative incisional hernia after hand-assisted laparoscopic surgery for colorectal liver metastasis.

Novel 3-(3, 5-difluoro-4-hydroxyphenyl)-1-(naphthalen-2-yl) prop-2-en-1-one as a potent inhibitor of MAP-kinase in HeLa cell lines and anti-angiogenic activity is mediated by HIF-1α in EAC animal model

In the present investigation, we synthesized chalcone bearing naphthalene compound d1, and on the basis of ¹H-NMR, ¹³C NMR, and LC-MS data we had specified the structure of the synthesized compound. The resultant compound d1 was assessed for their antiproliferative action against human cancer cell lines (HeLa, HCT116, HT29, MDA-MB-231, MCF-7, and SKBR3). The IC₅₀ range was estimated at 5.58 to 11.13 μM shows that compound d1 had remarkable anticancer activity on HeLa cell lines. Besides, it was discovered that d1 incited the mitochondrial apoptotic pathway by controlling Bax and Bcl-2 transcripts by expanding the Caspase 3 activation. We depicted the in-vivo effects of tumor advancement and the antiangiogenic activity of d1 in the EAC animal model. Tumor growth had inhibited and without symptoms the longevity of EAC containing mice expanded by the treatment of d1. Inhibition of nuclear transcriptional factor HIF-1α in EAC cells and finally it also inhibited phosphorylation of downstream signaling proteins such as ERK_1/2, p38, and JNK in HeLa cells. The present investigation uncovered that d1 indicated noteworthy tumor-repressing abilities much less concentration in in-vitro and in-vivo recommended that compound d1 as the potent anticancer medication.

The circular RNA 001971/miR-29c-3p axis modulates colorectal cancer growth, metastasis, and angiogenesis through VEGFA

Background

Colorectal cancer (CRC) is one of the most common malignant tumors globally. Angiogenesis is a key event maintaining tumor cell survival and aggressiveness. The expression of vascular endothelial growth factor A (VEGFA), one of the most significant tumor cell-secreted proangiogenic factors, is frequently upregulated in CRC.

Methods

The MTT assay was used to detect the viability of CRC cells. Transwell assays were performed to detect the invasion capacity of target cells. Relative protein levels were determined by immunoblotting. Pathological characteristics of tissues were detected by H&E staining and immunohistochemical (IHC) staining. A RIP assay was conducted to validate the predicted binding between genes.

Results

We observed that circ-001971 expression was dramatically increased in CRC tissue samples and cells. Circ-001971 knockdown suppressed the capacity of CRC cells to proliferate and invade and HUVEC tube formation in vitro, as well as tumor growth in mice bearing SW620 cell-derived tumors in vivo. The expression of circ-001971 and VEGFA was dramatically increased whereas the expression of miR-29c-3p was reduced in tumor tissue samples. Circ-001971 relieved miR-29c-3p-induced inhibition of VEGFA by acting as a ceRNA, thereby aggravating the proliferation, invasion and angiogenesis of CRC. Consistent with the above findings, the expression of VEGFA was increased, whereas the expression of miR-29c-3p was decreased in tumor tissue samples. miR-29c-3p had a negative correlation with both circ-001971 and VEGFA, while circ-001971 was positively correlated with VEGFA.

Conclusions

In conclusion, the circ-001971/miR-29c-3p axis modulated CRC cell proliferation, invasion, and angiogenesis by targeting VEGFA.

A Population-Based Study of Complications After Colorectal Surgery in Patients Who Have Received Bevacizumab

BACKGROUND

Patients receiving Bevacizumab, a vascular endothelial growth factor inhibitor used to treat metastatic colorectal cancer, may be at greater risk of complications after colorectal surgery because of impaired healing.

OBJECTIVE

The purpose of this study was to describe population-based rates of complications of colorectal surgery after Bevacizumab treatment and evaluate the relationship between time since last treatment and risk of complications.

DESIGN

This was a population-based retrospective cohort study using administrative and cancer registry data.

SETTINGS

The study was conducted in Ontario, Canada.

PATIENTS

Patients with metastatic colorectal cancer receiving Bevacizumab between January 2008 and December 2011 were followed for a year after treatment or until death.

MAIN OUTCOME MEASURES

Administrative data were used to identify patients who underwent colorectal surgery after initiation of Bevacizumab and to determine whether they experienced a complicated postoperative course. The relationship between time since last Bevacizumab treatment (≤28 d, 29 d to 3 mo, and >3 mo) and risk of postoperative complications was evaluated using logistic regression.

RESULTS

Of the 2759 patients who received Bevacizumab for the treatment of metastatic colorectal cancer, 265 underwent a colorectal procedure after exposure. The majority had a bowel resection or repair with no stoma (47.5%) and had emergency surgery (61.1%). Overall, 96 (36.2%) had a complicated postoperative course, including 20.4% readmission, 12.5% wound complications, and 7.9% mortality rate within 30 days of surgery. Adjusted multivariate analysis showed no difference in the likelihood of a complicated postoperative course among patients undergoing surgery within 28 days of receiving their last Bevacizumab dose compared with 29 days to 3 months (OR = 1.23 (95% CI, 0.53-2.84), or 3 to 12 months (OR = 0.98 (95% CI, 0.46-2.09) after receiving Bevacizumab.

LIMITATIONS

Reliance on administrative data to measure complications limited the scope of this study.

CONCLUSIONS

Patients with metastatic colorectal cancer requiring colorectal surgery after exposure to Bevacizumab experience substantial morbidity and mortality. The risk of complications is not detectably associated with time since exposure. See Video Abstract at http://links.lww.com/DCR/A474.

Peri-procedural use of anticoagulants in radiology: an evidence-based review

Peri-procedural anticoagulant management hinges on the balance of hemorrhagic and thrombotic complications. The radiologist is tasked with accurately assessing the hemorrhagic risk for patients undergoing procedures, taking into account procedural bleeding rates, underlying coagulopathy based on lab tests, and use of anticoagulants. The purpose of this article is to provide a contemporary review of commonly used anticoagulants and, incorporating published evidence, review their management related to image-guided procedures.

Dual-targeting anti-angiogenic cyclic peptides as potential drug leads for cancer therapy

Peptide analogues derived from bioactive hormones such as somatostatin or certain growth factors have great potential as angiogenesis inhibitors for cancer applications. In an attempt to combat emerging drug resistance many FDA-approved anti-angiogenesis therapies are co-administered with cytotoxic drugs as a combination therapy to target multiple signaling pathways of cancers. However, cancer therapies often encounter limiting factors such as high toxicities and side effects. Here, we combined two anti-angiogenic epitopes that act on different pathways of angiogenesis into a single non-toxic cyclic peptide framework, namely MCoTI-II (Momordica cochinchinensis trypsin inhibitor-II), and subsequently assessed the anti-angiogenic activity of the novel compound. We hypothesized that the combination of these two epitopes would elicit a synergistic effect by targeting different angiogenesis pathways and result in improved potency, compared to that of a single epitope. This novel approach has resulted in the development of a potent, non-toxic, stable and cyclic analogue with nanomolar potency inhibition in in vitro endothelial cell migration and in vivo chorioallantoic membrane angiogenesis assays. This is the first report to use the MCoTI-II framework to develop a 2-in-1 anti-angiogenic peptide, which has the potential to be used as a form of combination therapy for targeting a wide range of cancers.

Bevacizumab Combined with Chemotherapy Improves Survival for Patients with Metastatic Colorectal Cancer: Evidence from Meta Analysis

Background

Colorectal cancer is one of the leading causes of cancer deaths in both sexes in the world. Improvement of existing therapy modalities and implementing new ones in order to improve survival of patients with colorectal cancer represents a great challenge for medicine. The aim of this paper was to assess the impact that adding bevacizumab to chemotherapy has on survival in patients with metastatic colorectal cancer, compared to the use of chemotherapy alone.

Methods

Hazard ratios (HRs) with their 95% confidence intervals (CI) were determined from the studies and pooled. Two-sided p values were reported and considered to indicate statistical significance if less than 0.05.

Results

A total of 12 studies that meet the inclusion criteria were identified in the literature search, 3 phase II studies and 9 phase III studies. Based on the random effects meta-analysis, a statistically significant improvement was identified for both overall survival (HR = 0.84; 95% CI: 0.74–0.94; p = 0.003) and progression free survival (HR = 0.64; 95% CI: 0.55–0.73; p<0.00001) in patients with metastatic colorectal cancer when bevacizumab was added to chemotherapy, compared to chemotherapy treatment alone.

Conclusion

The findings of this meta analysis confirm the benefit of adding bevacizumab to chemotherapy in terms of survival and progression free survival, but the magnitude of this effect is not consistent throughout the included studies. This suggests the need for further research of interaction of bevacizumab with chemotherapeutic agents as well as recognition of patients’ characteristics important for the treatment selection criteria.

Incisional hernia after open resections for colorectal liver metastases - incidence and risk factors

BACKGROUND

Incisional hernia is one of the most common complications after laparotomy. The aim of this retrospective study was to investigate incidence, location and risk factors for incisional hernia after open resection for colorectal liver metastases including the use of perioperative chemotherapy and targeted therapy evaluated by computed tomography.

METHODS

Patients operated for colorectal liver metastases between 2010 and 2013 were included. Incisional hernia was defined as a discontinuity in the abdominal fascia observed on computed tomography.

RESULTS

A total of 256 patients were analyzed in regard to incisional hernia. Seventy-eight patients (30.5%) developed incisional hernia. Hernia locations were midline alone in 66 patients (84.6%) and involving the midline in another 8 patients (10.3%). In multivariate analysis, preoperative chemotherapy >6 cycles (hazard ratio 2.12, 95% confidence interval 1.14-3.94), preoperative bevacizumab (hazard ratio 3.63, 95% confidence interval 1.86-7.08) and incisional hernia from previous surgery (hazard ratio 3.50, 95% confidence interval 1.98-6.18) were found to be independent risk factors.

CONCLUSIONS

Prolonged preoperative chemotherapy and also preoperative bevacizumab were strong predictors for developing an incisional hernia. After an extended right subcostal incision, the hernia location was almost exclusively in the midline.

A novel engineered VEGF blocker with an excellent pharmacokinetic profile and robust anti-tumor activity

BACKGROUND

Relatively poor penetration and retention in tumor tissue has been documented for large molecule drugs including therapeutic antibodies and recombinant immunoglobulin constant region (Fc)-fusion proteins due to their large size, positive charge, and strong target binding affinity. Therefore, when designing a large molecular drug candidate, smaller size, neutral charge, and optimal affinity should be considered.

METHODS

We engineered a recombinant protein by molecular engineering the second domain of VEGFR1 and a few flanking residues fused with the Fc fragment of human IgG1, which we named HB-002.1. This recombinant protein was extensively characterized both in vitro and in vivo for its target-binding and target-blocking activities, pharmacokinetic profile, angiogenesis inhibition activity, and anti-tumor therapeutic efficacy.

RESULTS

HB-002.1 has a molecular weight of ~80 kDa, isoelectric point of ~6.7, and an optimal target binding affinity of <1 nM. The pharmacokinetic profile was excellent with a half-life of 5 days, maximal concentration of 20.27 μg/ml, and area under the curve of 81.46 μg·days/ml. When tested in a transgenic zebrafish embryonic angiogenesis model, dramatic inhibition in angiogenesis was exhibited by a markedly reduced number of subintestinal vessels. When tested for anti-tumor efficacy, HB-002.1 was confirmed in two xenograft tumor models (A549 and Colo-205) to have a robust tumor killing activity, showing a percentage of inhibition over 90% at the dose of 20 mg/kg. Most promisingly, HB-002.1 showed a superior therapeutic efficacy compared to bevacizumab in the A549 xenograft model (tumor inhibition: 84.7% for HB-002.1 versus 67.6% for bevacizumab, P<0.0001).

CONCLUSIONS

HB-002.1 is a strong angiogenesis inhibitor that has the potential to be a novel promising drug for angiogenesis-related diseases such as tumor neoplasms and age-related macular degeneration.

Combined modalities treatment of pulmonary metastasis from an urachal adenocarcinoma

Urachal adenocarcinoma is a rare neoplasm of the bladder. Most of these tumors arise from urachal remnants in the dome of the bladder and extend into the umbilicus. These tumors can recur and most commonly metastasize to lymph nodes, retroperitoneum, lungs, liver and bone. Here we report a case of an urachal adenocarcinoma followed for seven years with lung metastasis for three years.

Role of bevacizumab in colorectal cancer growth and its adverse effects: A review

Angiogenesis affects both wound healing and malignant cell growth through nutrients and oxygen. Vascular endothelial growth factor (VEGF) is the most important element involved in this complex process. Inhibition of VEGF influences angiogenesis and may restrict tumor growth and metastatic ability. Modern anti-angiogenic therapy is based on this theory. Bevacizumab is a recombinant humanized monoclonal antibody (immunoglobulin G1) which binds with VEGF-A forming a large molecule. It can not be bound with VEGF tyrosine kinase receptors preventing VEGF-A incorporation; thus its activity is inhibited inducing blockage of VEGF-mediated angiogenesis. Bevacizumab, in combination with chemotherapy or other novel targeted therapeutic agents, is currently used more frequently in clinical practice, mainly for managing advanced colorectal cancer. It is also used for managing other malignancies, such as breast cancer, pancreatic cancer, prostate cancer, non small-cell lung cancer, metastatic renal carcinoma and ovarian tumors. Although it is generally considered a safe treatment, there are reports of some rare side effects which should be taken into account. Recent experiments in rats and mice show promising results with a wider therapeutic range.

Effects of Intraperitoneal Bevacizumab Administration on Colonic Anastomosis and Early Postoperative Adhesion Formation

Aim. The purpose of this study is to investigate the effect of intraperitoneal (IP) bevacizumab on colonic anastomosis and evaluate the effects on early postoperative adhesion formation. Materials and Methods. A total of 24 mature female Sprague-Dawley rats were used for this study. Rats were randomly assigned to a control group that received saline (n = 8) or to experimental groups (n = 8 each) that received bevacizumab at a dose of 2.5 mg/kg (group 1) or 5 mg/kg (group 2). Animals were killed humanely on the seventh day after operation, and measurements of anastomotic strength and biochemical variables were performed. Results. The mean adhesion grade was 2.63 ± 0.92, and 1 ± 0.93 and 0.75 ± 0.71 for the control and test groups, respectively. Bevacizumab significantly reduced adhesion formation in both low-dose and high-dose IP applications ( P < .05). When all groups were compared, it was found that VEGF levels decreased significantly only in the tissue ( P = .001), whereas there was no significant difference in the blood and the IP fluid ( P = .73 and .08, respectively). We evaluated hydroxyproline levels, anastomosis bursting pressure, and histopathological healing scores. When each of these parameters were examined, there was statistical difference between groups ( P = .01, .004, and .01, respectively). It was found that these parameters significantly decreased depending on increasing drug dose. Conclusion. IP administration of bevacizumab effectively reduced the formation of adhesions and caused significant impairment of anastomotic wound healing when standard doses were administered (5 mg/kg), but the 2.5-mg/kg dosage did not affect the anastomotic wound healing and also effectively reduced the formation of adhesions.

The effect of intravitreal bevacizumab and ranibizumab on cutaneous tensile strength during wound healing

Purpose

To investigate the effect of intravitreal bevacizumab and ranibizumab on wound tension and by histopathology during cutaneous wound healing in a rabbit model and to compare this effect to placebo intravitreal saline controls 1 and 2 weeks following intravitreal injection.

Methods

A total of 120 New Zealand white rabbits were randomly assigned to one of three treatment groups each consisting of 40 rabbits. Each group received intravitreal injections of bevacizumab, ranibizumab, or normal saline. Immediately afterwards, each rabbit underwent four 6 mm full-thickness dermatologic punch biopsies. Twenty rabbits from each agent group underwent wound harvesting on day 7 or day 14. The skin samples were stained for CD34 for vascular endothelial cells on day 7, and maximal wound tensile load was measured on days 7 and 14. Quantitative assessment of mean neovascularization (MNV) scores was obtained from 10 contiguous biopsy margin 400× fields of CD34-stained sections by two independent observers.

Results

Wound tension reading means (N) with standard error and adjusted P-values on day 7 were: saline placebos, 7.46 ± 0.87; bevacizumab, 4.50 ± 0.88 (P = 0.041); and ranibizumab, 4.67 ± 0.84 (P = 0.025). On day 14 these were: saline placebos, 7.34 ± 0.55; bevacizumab, 6.05 ± 0.54 (P = 0.18); and ranibizumab 7.99 ± 0.54 (P = 0.40). MNV scores in CD34 stained sections were: saline controls, 18.31 ± 0.43; bevacizumab, 11.02 ± 0.45 (P < 0.0001); and ranibizumab, 13.55 ± 0.43 (P < 0.0001). The interobserver correlation coefficient was 0.928.

Conclusion

At day 7, both anti–vascular endothelial growth factor (anti-VEGF) agents had significantly suppressed MNV scores and exerted a significant reduction of cutaneous wound tensile strength compared with saline controls. At day 14, neither agent produced a significant effect on tensile wound strength. Since angiogenesis is an integral component of the proliferative phase of wound healing, we encourage clinicians to be aware of their patients’ recent surgical history during intravitreal anti-VEGF therapy and to consider refraining from their use during the perioperative period.

The effect of intravitreal anti-VEGF agents on peripheral wound healing in a rabbit model

Purpose

To investigate the effect of intravitreal pegaptanib, bevacizumab, and ranibizumab on blood-vessel formation during cutaneous wound healing in a rabbit model and to compare this effect to placebo controls.

Methods

Forty New Zealand albino rabbits underwent full thickness cutaneous wounds using 6-mm dermatologic punch biopsies. The rabbits were assigned to four groups of ten, each receiving intravitreal injections of pegaptanib, bevacizumab, ranibizumab, or no injection (untreated controls). Five rabbits from each group underwent wound harvesting on day 7 and five from each group on day 14. The skin samples were stained with hematoxylin and eosin (HE), Masson’s trichrome (MT), and CD34 for vascular endothelial cells. Semiquantitative evaluation of HE- and MT-stained slides was performed by one pathologist. Quantitative assessment of mean neovascularization (MNV) scores was obtained from five contiguous biopsy margin 400× fields of CD34-stained sections by four independent observers.

Results

Week 1 MNV scores in CD-34 stained sections were: untreated controls: 11.51 ± 4.36; bevacizumab: 7.41 ± 2.82 (P = 0.013); ranibizumab: 8.71 ± 4.08 (P = 0.071); and pegaptanib: 10.15 ± 5.59 (P = 0.378). Week 2 MNV data were: untreated controls: 6.14 ± 2.25; bevacizumab: 7.25 ± 2.75 (P = 0.471); ranibizumab: 4.53 ± 3.12 (P = 0.297); and, pegaptanib: 6.35 ± 3.09 (P = 0.892). Interobserver variability using intraclass correlation coefficient was 0.961.

Conclusions

At week 1, all three anti-VEGF agents had suppressed MNV scores compared to controls. Although not statistically significant, there was an inhibitory trend, particularly with bevacizumab and ranibizumab. These effects were diminished at 2 weeks, reflecting a transition between the proliferative and remodeling phases of wound healing.

Safety of bevacizumab in metastatic breast cancer patients undergoing surgery

BACKGROUND

Evaluate the safety of surgery in relation to bevacizumab in the first-line treatment of metastatic breast cancer (mBC) in two international trials.

PATIENTS AND METHODS

The incidence, type and timing of post-surgical bleeding events and wound-healing complications were assessed in surgical patients in the AVastin And DOcetaxel (AVADO) (NCT00333775) and Avastin THErapy for advaNced breAst cancer (ATHENA) (NCT00448591) trials. Both study protocols followed recommendations to withhold bevacizumab for at least 6 weeks before elective surgery and to wait 28 days (or until the wound was fully healed) after major surgery before recommencing bevacizumab therapy.

RESULTS

In AVADO, 221 surgical procedures (55 major, 166 minor) were performed in 155 patients. In ATHENA, 1190 surgical procedures (435 major, 755 minor) were performed in 672 patients. One bevacizumab-treated AVADO patient (0.9%) who underwent surgery experienced a grade 3 bleeding event. In ATHENA, six patients (0.9%) who underwent surgery experienced grade 3 bleeding events and one patient (0.1%) experienced a grade 4 bleeding event. No grade 5 bleeding events in patients undergoing surgery were reported in either study. One grade 3 wound-healing complication was reported in each of the AVADO arms: placebo (n=46, 2.2%), bevacizumab 7.5mg/kg (n=57, 1.8%) and bevacizumab 15mg/kg (n=52, 1.9%). Incidence of grade 3-4 wound-healing complications in ATHENA was 2.2% and 1.3% in patients undergoing minor or major surgery, respectively.

CONCLUSIONS

Surgery can be performed on patients with mBC undergoing bevacizumab therapy with a low risk of severe bleeding or wound-healing complications post surgery, if current labelling recommendations are adhered to.

The effect of antivascular endothelial growth factor on the development of adhesion formation in laparotomized rats: experimental study

Aims. This study determined the effects of a single dose of bevacizumab, an antiangiogenic recombinant monoclonal antibody that specifically targets vascular endothelial growth factor (VEGF), on adhesion formation in the rat cecal abrasion model. Methodology. Thirty female Wistar albino rats (200-224 g) were divided into three groups. All rats underwent laparotomy at which time cecal wall abrasion and abdominal wall injuries were induced. Group I (control) underwent only the abrasion procedure; Groups II and III received saline or bevacizumab intraperitoneally, respectively, following the abrasion. The rats were killed on postoperative day 7, and the severity of adhesions was evaluated, together with histopathological fibrosis parameters and immunohistochemical staining to identify the VEGF receptor. Results. The mean adhesion severity score in Groups I-III was 2.5 ± 0.52, 2.4 ± 0.69, and 0.7 ± 0.82, respectively; the score in Group III was significantly lower than that in Groups I (P < 0.001) and II (P < 0.001). In the histopathological evaluation, the mean fibrosis score in Group III was significantly lower that the scores in Groups I (P < 0.001) and II (P < 0.001). VEGF staining of the adhesion areas in Group III was significantly lower than that in Groups I (P < 0.001) and II (P < 0.001). Conclusion. Bevacizumab decreases adhesion formation following laparotomy in rats by blocking VEGF receptor occupancy.

Intraperitoneal administration of bevacizumab intraoperatively does not affect abdominal wound healing in rats

BACKGROUND

Bevacizumab is a monoclonal antibody targeted at vascular endothelial growth factor (VEGF) to treat advanced colorectal cancer as well as other malignancies, but the ideal time point for its administration in patients scheduled for surgery is not well defined due to serious concerns regarding possible side effects on wound healing. Therefore, we conducted an experimental study in rats to clarify this issue.

METHODS

Four groups of 10 Wistar rats each underwent a 4-cm midline laparotomy and closure of the wound in 2 layers. In the treatment groups (A and B), bevacizumab (Avastin(®)) received a single dose of 5 mg/kg i.p., and an equal amount of saline was given to the control groups (C and D). Groups A and C were sacrificed on the 7th postoperative day, and groups B and D on the 14th postoperative day. Wounds were inspected by two independent observers upon sacrifice and results were recorded; wound tissues were sent for histology to assess the degree of fibrosis and measurement of tissue hydroxyproline levels. Serum levels of endothelin-1, C-reactive protein, pro-oxidant/antioxidant balance and carbonylated proteins were also determined. For statistical analysis, the Mann-Whitney U test was used.

RESULTS

Wound healing did not differ among groups both on the 7th and the 14th postoperative days, and there was also no significant difference regarding the degree of inflammation, fibroblast proliferation and collagen synthesis, as well as hydroxyproline and biochemical marker levels among the groups.

CONCLUSIONS

Intraperitoneal bevacizumab administered intraoperatively does not significantly affect abdominal wound healing in rats.

The effect of bevacizumab on colon anastomotic healing in rats

PURPOSE

The aim of the study was to investigate the effect of angiogenesis inhibition by bevacizumab, a monoclonal anti-vascular endothelial growth factor (VEGF) antibody, on the healing process of colonic anastomoses in rats, assessing some specific involved factors. This new agent is used mainly in metastatic colorectal cancer. The angiogenesis plays an important role in both wound healing and metastatic invasion and spread of malignant cells. There has not been any evidence assessing the optimal time for its safe use in operated patients.

MATERIALS AND METHODS

Forty Wistar rats were randomly allocated into four equal groups. A colonic anastomosis was performed in all rats. Half of them received intraoperatively a single dose of bevacizumab 5 mg/body weight and the rest received placebo. The animals were sacrificed on the 7th (Avastin 7th, placebo 7th) and 14th (Avastin 14th, placebo 14th) postoperative day. The anastomosis was resected and sent for histological study and for tissue biochemical assays (VEGF, endothelin-1 (ET-1), C-reactive protein (CRP), pro-oxidant-antioxidant balance (PAB), carbonylated proteins, hydroxyproline) using specific enzyme-linked immunosorbent assay kits. For statistical analysis, the Mann-Whitney U test was used (of statistical significance when P < 0.05).

RESULTS

No complication or anastomotic dehiscence was observed. Histology did not reveal statistically significant differences between groups concerning degree of inflammation, fibroblasts, collagen, and fibrosis. Likewise, hydroxyproline levels did not differ. However, some statistically significant differences were found in VEGF, CRP and carbonyl proteins (Avastin 7th vs placebo 7th, placebo 14th vs placebo 7th), ET-1, and PAB (Avastin 14th vs Avastin 7th), which did not finally affect the collagen synthesis marker hydroxyproline, nor did the anastomotic strength.

CONCLUSIONS

Bevacizumab, when administered intraoperatively, has no significant effect on colon anastomotic healing in rats despite a transient mild ischemia.

Timing of administration of bevacizumab chemotherapy affects wound healing after chest wall port placement

BACKGROUND

The authors investigated how the timing of administration of bevacizumab, a targeted vascular endothelial growth factor-inhibiting chemotherapeutic agent, affected the risk of wound healing in patients undergoing chest wall port placement.

METHODS

The authors performed a retrospective search was performed of an institutional review board approved, Health Insurance Portability and Accountability Act compliant database between 2002 and 2008, identifying 1108 port placements in patients who were treated with bevacizumab. One hundred twenty of these ports eventually required explant. Data analyzed included patient demographics, indication for port removal, and schedule of bevacizumab therapy.

RESULTS

Wound healing complications requiring port explant were seen in 0.9% of placements (10/1108). When bevacizumab was given within 1 day of port placement, the absolute risk (AR) of port removal for wound dehiscence was 2.4% (2/82), compared with 0.3% (3/1021) when 2 or more days had passed between port placement and bevacizumab administration, yielding a statistically significant relative risk (RR) of 8.1 (P < .02). Similarly, when bevacizumab was administered within 7 days of port insertion, there was a significant RR of dehiscence-related port explant (AR 1.4% vs 0.1%, RR 11.5, P < .028). However, no significant RR for dehiscence-related port removal was observed when bevacizumab was administered within 14 days (AR 0.9% vs 0.2%, RR 6.2, P < .09) or 30 days (AR 0.7% vs 0.2%, RR 3.7, P < .23) of port placement.

CONCLUSIONS

The risk of a wound dehiscence requiring chest wall port explant in patients treated with bevacizumab was inversely proportional to the interval between bevacizumab administration and port placement, with significantly higher risk seen when the interval is less than 14 days.

Impacts of cytosolic phospholipase A2, 15-prostaglandin dehydrogenase, and cyclooxygenase-2 expressions on tumor progression in colorectal cancer

PURPOSE

In addition to cyclooxygenase-2 (COX-2) which is related to prostaglandin E2 synthesis, other enzymes such as cytosolic phospholipase A2 (cPLA2), microsomal prostaglandin E2 synthase-1 (mPGES-1), and 15-prostaglandin dehydrogenase (15-PGDH) have been suggested to be related to carcinogenesis of colorectal cancer (CRC). The aim of this study was to investigate the roles of cPLA2, COX-2, mPGES-1, and 15-PGDH in tumor progression.

MATERIALS AND METHODS

cPLA2, COX-2, mPGES-1, 15-PGDH, and vascular endothelial growth factor (VEGF) expressions were immunohistochemically examined in 89 CRC, and their expressions were compared with each other or clinicopathologic parameters as well as VEGF as tumor progression parameters.

RESULTS

cPLA2 was expressed in 54.5%, COX-2 in 80.5%, mPGES-1 in 96.4%, 15-PGDH in 46.1%, and VEGF in 65.9%. The expression of cPLA2 correlated with VEGF expression. COX-2 expression was correlated with the depth of invasion, tumor stage, cPLA2, and VEGF expressions. Moreover, VEGF revealed the highest expression in the tissues positive for both cPLA2 and COX-2. Furthermore, 15-PGDH expression was inversely correlated with VEGF expression.

CONCLUSION

The present study demonstrates that cPLA2 and mPGES-1, in addition to COX-2, are constitutively overexpressed, and that 15-PGDH might be attenuated in colorectal cancer. Furthermore, cPLA2 and 15-PGDH as well as COX-2 could have an important role in tumor progression.

[Bevacizumab and non-small cell lung cancer: a new step?]

Inhibition of specific processes essential for tumour vascular development is one of the key strategies for the treatment of non- small cell lung cancer (NSCLC). Many agents target the Vascular Endothelial Growth Factor (VEGF) pathway, either by preventing VEGF receptor binding or inhibiting VEGF receptor signalling in endothelial cells. Bevacizumab is a monoclonal antibody specific for VEGF-A. Combination of bevacizumab with standard first-line chemotherapy in NSCLC leads to an improvement in response rates and progression-free survival compared to chemotherapy alone and a significant survival advantage with carboplatin- paclitaxel chemotherapy. Toxicity issues are of concern with the possible occurrence of hypertension and an increased risk of arterial thrombo-embolism. The occurrence of fatal pulmonary haemorrhage after necrosis of the primary tumour is a specific toxicity in NSCLC which requires appropriate selection of patients before treatment; excluding squamous cell carcinoma, haemorrhagic tumours and tumour invasion of major blood vessels. The use of bevacizumab combined with chemotherapy represent a first step in the development of antiangiogenic treatments in NSCLC, with the future possibility of using it in earlier stages of disease.

Emergency surgery in the era of molecular treatment of solid tumours

In the advancing era of molecular therapy of solid tumours, emergency treatment of complications, such as bowel perforation, haemorrhage, and tumour rupture, is likely to evolve into one of the main challenges of surgical oncology. These complications might be caused by disease progression from resistance to therapy, side-effects of therapy on normal vasculature, and therapeutic induction of excessively responding tumours. This Review outlines the probability and management of emergency operations during molecularly targeted therapy of solid tumours. Special attention is given to advanced gastrointestinal stromal tumours and colorectal cancer, and therapy with imatinib, sunitinib, and bevacizumab.

Selective targeting of the tumour vasculature

Selective targeting of the tumour vasculature in the treatment of solid organ malignancies is an alternative to conventional chemotherapy treatment. As the tumour progressively increases in size, angiogenesis or the formation of new vasculature is essential to maintain the tumour's continual growth and survival. Therefore disrupting this angiogenic process or targeting the neovasculature can potentially hinder or prevent further tumour expansion. Many anti angiogenic agents have been investigated with many currently in clinical trials and exhibiting varied results. Vascular disrupting agents such as the Combretastatins and OXi 4503 have shown promising preclinical results and are currently being examined in clinical trials.

Perioperative GMCSF limits the proangiogenic plasma protein changes associated with colorectal cancer resection

AIMS

Colorectal resection (CR) increases plasma VEGF levels which may promote residual tumor growth. This study assessed the effect of perioperative GMCSF on plasma levels of sVEGFR1, Ang-1 and Ang-2 and also the impact of post-GMCSF plasma on in vitro endothelial cell (EC) growth and invasion. Ang-2 increases while sVEGFR1 and Ang-1 impede angiogenesis.

METHODS

Fifty-nine CR cancer patients were randomized to 7 perioperative doses of GMCSF or saline for 3days prior and 4days after CR. Blood samples were taken pre-drug (PreRx) and on several postoperative days (POD). Protein levels were assessed and PreRx and POD 5 plasma added to EC cultures after which branch point formation (ECBPF) and invasion (ECI) were measured.

RESULTS

sVEGFR1 levels were significantly higher on POD 1 and POD 5 in both groups but the GMCSF POD 5 level was twice the control value (p=0.002). Ang-2 levels were higher on PODs 1 and 5 in both groups (p<0.05) but the control POD 5 value (vs. GMCSF) was greater (p=0.03). Ang-1 decreases were noted in all (p=not significant, ns). The control group POD 5 ECBPF was 35.8% greater than Pre Rx (p=0.001) while the GMCSF result was 18.0% lower (p=ns); the control POD 5 median percent change from baseline was greater than the GMCSF result(p=0.008). The POD 5 ECI was +12.2% for the control group vs. baseline (p=ns) and -17.2% for the GMCSF group (p=ns): the control median percent change was greater than in the GMCSF group(p=0.045).

CONCLUSION

CR-related plasma changes are proangiogenic (>Ang-2) and anti-angiogenic (>sVEGFR1); the net effect is promotion of in vitro ECBPF. GMCSF limits the proangiogenic changes (higher POD 5 sVEGFR1 levels and lower Ang-2 elevations, lower POD 5 ECBPF and ECI). The clinical import of these effects is unclear; perioperative GMCSF has anti-angiogenic plasma effects that may limit tumor growth. Further investigation is warranted.

[Efficacy and tolerance of bevacizumab in non-small cell lung cancer: preliminary report]

INTRODUCTION

Bevacizumab is an antiangiogenic drug targeting VEGF. Its interest, in combination with chemotherapy, has been demonstrated in two recent trials in metastatic non-small cell lung cancer and its approval is awaited within few weeks. Due its original mechanism of action, bevacizumab has a very specific safety profile and radiological response patterns.

METHOD

Based upon selected observations reported from patients included in clinical trials and on recent literature, we bring some clue for a better and safer use of bevacizumab.

RESULTS

We report toxicity associated with bevacizumab, especially vascular side-effects and unusual radiological responses.

CONCLUSION

Bevacizumab use in NSCLC is associated with some unexpected side effects and responses that worth to be known by pulmonologists. Selections criteria should be rigorously followed.

A cryptic vascular endothelial growth factor T-cell epitope: identification and characterization by mass spectrometry and T-cell assays

Vascular endothelial growth factor (VEGF) is involved in various physiologic processes, such as angiogenesis or wound healing, but is also crucial in pathologic events, such as tumor growth. Thus, clinical anti-VEGF treatments have been developed that could already show beneficial effects for cancer patients. In this article, we describe the first VEGF-derived CD8(+) T-cell epitope. The natural HLA ligand SRFGGAVVR was identified by differential mass spectrometry in two primary renal cell carcinomas (RCC) and was significantly overpresented on both tumor tissues. SRFGGAVVR is derived from a cryptic translated region of VEGF presumably by initiation of translation at the nonclassic start codon CUG(499). SRFGGAVVR-specific T cells were generated in vitro using peptide-loaded dendritic cells or artificial antigen-presenting cells. SRFGGAVVR-specific CD8(+) T cells, identified by HLA tetramer analysis after in vitro stimulation, were fully functional T effector cells, which were able to secrete IFN-gamma on stimulation and killed tumor cells in vitro. Additionally, we have quantitatively analyzed VEGF mRNA and protein levels in RCC tumor and normal tissue samples by gene chip analysis, quantitative reverse transcription-PCR, in situ hybridization, and bead-based immunoassay. In the future, T cells directed against VEGF as a tumor-associated antigen may represent a possible way of combining peptide-based anti-VEGF immunotherapy with already existent anti-VEGF cancer therapies.

"Spontaneous," delayed colon and rectal anastomotic complications associated with bevacizumab therapy

Bevacizumab, a humanized monoclonal antibody used to treat recurrent and metastatic colorectal cancer, targets the vascular endothelial growth factor (VEGF) molecule. It is hypothesized that bevacizumab works by both depriving tumors of the neovascularity they require to grow, and by improving local delivery of chemotherapy through alterations of tumor vasculature permeability and Starling forces. Complications of bevacizumab treatment include bowel ischemia and perforation, but to date, these complications have only rarely been described as occurring at the site of presumably healed anastomoses following surgery. We report two cases of delayed, "spontaneous" low anterior colorectal anastomotic dehiscence and one right colon anastomotic colocutaneous fistula associated with bevacizumab therapy. After seeing three patients with complications arising from apparently healed low anterior colorectal or right colon anastomoses following initiation of bevacizumab therapy for treatment of metastatic colorectal cancer, we reviewed the experience of The Cancer Institute of New Jersey (CINJ) with use of bevacizumab in approximately 50 patients between April 2004 and December 2006. The three index cases had been treated surgically at CINJ but received chemotherapy elsewhere. None of the 50 patients receiving bevacizumab at CINJ who had previous colon or rectal anastomoses were identified as having this complication. The medical records of the three index cases were reviewed and analyzed. Additionally, a Medline search was performed to identify other reports documenting similar cases. Two reports of related cases were found in the literature. In two of our index cases who underwent low anterior anastomoses, the patients had received preoperative pelvic irradiation before their initial low anterior resection. In one of the two cases, the initial resection was complicated by an anastomotic leak requiring proximal diversion and then subsequent stoma takedown. In both cases, the dehiscence occurred more than 1 year after anastomosis, and became evident 1-10 months following initiation of bevacizumab treatment. In the third index case, a colocutaneous fistula arising from the anastomotic site presented 5 months following right colon resection and 3 months after starting adjuvant systemic therapy with FOLFOX (5-fluorouracil (5-FU), leucovorin, and oxaliplatin) and bevacizumab. Delayed colorectal anastomotic complications may occur in association with bevacizumab therapy. Contributing factors may include anastomotic leak at the time of the original operation and history of anastomotic irradiation. Clinicians treating patients who receive bevacizumab following colectomy for colorectal cancer should be aware of this possible life-threatening complication. These findings may also be relevant to the design of trials of the use of bevacizumab for the postoperative adjuvant treatment of patients with colorectal cancer.

Gastrointestinal ulceration as a possible side effect of bevacizumab which may herald perforation

Chemotherapy plus bevacizumab is currently considered as the standard 1st line treatment of advanced colorectal cancer (ACC). Whereas GI perforation is a known side effect of bevacizumab, the development of GI ulcers has not been reported. We identified 18 patients with ACC who participated in a phase III multicentre trial which included chemotherapy and bevacizumab, who developed a GI ulcer (n = 6), perforation (n = 8) or both (n = 4). The risk of developing a symptomatic GI ulcer or perforation was 1.3% and 1.6%, respectively. Central review of the histology specimens showed ulceration and/or granulation tissue with neovascularisation. The majority (89%) of events developed early during treatment. Given these observations, as well as the relationship between VEGF and mucosal injury healing, we suggest that GI ulcers may occur as a side effect of treatment with bevacizumab and may herald perforation.

Quality of life after rectal resection and multimodality therapy

Modern management of locally advanced rectal cancer requires a multimodality approach. This includes radical surgery, pelvic radiotherapy, and systemic chemotherapy. It can require a permanent colostomy and result in significant bowel, sexual, and urinary dysfunction. In order to determine the effectiveness of various multimodality regimens it is important to not only assess conventional oncologic outcomes but also the impact on patient's quality of life.

Metinel node--the first lymph node draining a metastasis--contains tumor-reactive lymphocytes

Background

We previously identified tumor-reactive lymphocytes in the first lymph nodes that drain the primary tumor. In this study, we performed lymphatic mapping to investigate the possibility of finding the first lymph nodes that drain metastases, and of learning whether these lymph nodes contained tumor-reactive lymphocytes suitable for adoptive immunotherapy.

Methods

Nineteen patients were studied. The primary tumor site was colorectal cancer in seven patients, malignant melanoma in four, ovarian cancer and breast cancer in two, and one each with pancreatic cancer, cholangiocarcinoma, leiomyosarcoma, and squamous cellular cancer of the tongue. By injection of Patent blue dye or radioactive tracers around the metastases, we identified draining lymph nodes from liver metastases (n = 9), intra-abdominal local recurrences (n = 3), and regional lymph node metastases (n = 7). In six patients, a preoperative lymphoscintigraphy was performed.

Results

We located the first draining lymph node or nodes from metastases or local recurrences; we named them “metinel nodes.” Lymphocytes from the metinel nodes proliferated, showed clonal expansion, and produced interferon gamma (via in vitro expansions on stimulation with tumor homogenate) and interleukins, all of which demonstrate the characteristics of tumor-reactive lymphocytes. Eight of the nineteen patients received immunotherapy on the basis of tumor-reactive T cells derived from the metinel nodes.

Conclusions

We demonstrate that it is possible to locate the first lymph nodes draining subcutaneous, lymphatic, and visceral metastases, the so-called metinel nodes. Metinel node–derived lymphocytes may be used to treat disseminated solid cancer, and clinical trials should evaluate the effect of such treatment.