FOLFOX4 versus sequential dose-dense FOLFOX7 followed by FOLFIRI in patients with resectable metastatic colorectal cancer (MIROX): a pragmatic approach to chemotherapy timing with perioperative or postoperative chemotherapy from an open-label, randomized phase III trial

BACKGROUND

Perioperative FOLFOX4 (oxaliplatin plus 5-fluorouracil/leucovorin) chemotherapy is the current standard in patients with resectable metastases from colorectal cancer (CRC). We aimed to determine whether a sequential chemotherapy with dose-dense oxaliplatin (FOLFOX7) and irinotecan (FOLFIRI; irinotecan plus 5-fluorouracil/leucovorin) is superior to FOLFOX4. The chemotherapy timing was not imposed, and was perioperative or postoperative.

PATIENTS AND METHODS

In this open-label, phase III trial, patients with resectable or resected metastases were randomly assigned either to 12 cycles of FOLFOX4 (oxaliplatin 85 mg/m(2)) or 6 cycles of FOLFOX7 (oxaliplatin 130 mg/m(2)) followed by 6 cycles of FOLFIRI (irinotecan 180 mg/m(2)). Randomization was done centrally, with stratification by chemotherapy timing, type of local treatment (surgery versus radiofrequency ablation with/without surgery), and Fong's prognostic score. The primary end point was 2-year disease-free survival (DFS).

RESULTS

A total of 284 patients were randomized, 142 in each treatment group. Chemotherapy was perioperative in 168 (59.2%) patients and postoperative in 116 (40.8%) patients. Perioperative chemotherapy was preferentially proposed for synchronous metastases, whereas postoperative chemotherapy was more frequently used for metachronous metastases. Two-year DFS was 48.5% in the FOLFOX4 group and 50.0% in the FOLFOX7-FOLFIRI group. In the multivariable analysis, more than one metastasis [hazard ratio (HR) = 2.15] and synchronous metastases (HR = 1.63) were independent prognostic factors for shorter DFS. Five-year overall survival (OS) rate was 69.5% with FOLFOX4 versus 66.6% with FOLFOX7-FOLFIRI.

CONCLUSIONS

FOLFOX7-FOLFIRI is not superior to FOLFOX4 in patients with resectable metastatic CRC. Five-year OS rates observed in both groups are the highest ever reported in this setting, possibly reflecting the pragmatic approach to chemotherapy timing.

CLINICAL TRIALS NUMBER

NCT00268398.

Conservative surgery vs. duodeneopancreatectomy in primary duodenal gastrointestinal stromal tumors (GIST): a retrospective review of 114 patients from the French sarcoma group (FSG)

BACKGROUND

Duodenal GISTs represent 3-5% of all GISTs with limited understanding of patient outcomes. We conducted a retrospective analysis of primary localized duodenal GISTs.

METHODS

Patients were identified via a survey from 16 FSG centers (n = 105), and a group of 9 patients enrolled in the BFR14 trial. Data were collected from the original database and patient files, in agreement with French legislation.

RESULTS

114 patients were included, with a median age of 57. Tumors originated mainly in D2 (33%), or D3 (24%), with a median size of 5 cm. 109 patients had resection of the primary tumor; with a Local Resection (LR, n = 82), a pancreaticoduodenectomy (PD, n = 23), and data were missing for 4 patients. Resections were R0 (n = 87, 79%), R1 (n = 8, 7%), R2 (n = 6). Tumor characteristics were: KIT+ (n = 104), CD34+ (n = 58). Miettinen risk was low (n = 43), and high (n = 52). Imatinib was administered preoperatively (n = 11) and post-operatively (n = 20). With a median follow-up of 36 months (2-250), 98 patients are alive, and 33 relapsed. The 5-year OS and EFS rates are 86.5% and 54.5%. EFS was similar for patients in the LR and the PD groups (P > 0.05). In multivariate analysis, ECOG PS, and CD34 expression are independent prognostic factors on OS. Miettinen risk and spindle cell type are independent predictive factors for relapse.

CONCLUSIONS

Patients with resected duodenal GIST have a reasonably favorable prognosis. This study favors a preservation of pancreas when there are no anatomical constraints. LR exhibit similar survival and smaller morbidity then PD.

Outcome of colon cancer patients with synchronous metastases

4029

Background: Metastatic colon cancer patients may undergo chemotherapy without colon surgery. However, the outcome of patients has not been evaluated and antiagiogenic agents can not be given. The aim of the present cohort study was to analyse factors influencing patients’ survival. Methods: Consecutive patients [N=228, mean age (sd) 64 (12) yrs, median follow-up 20 mths;84 females] treated in 6 teaching hospitals received chemotherapy for metastatic colonic cancer, either as the first step, or after surgery. Progressive free survival (PFS) was estimated using Kaplan-Meïer method. Factors associated with PFS were tested by means of Log rank test and results are presented in terms of medians of survival (95% CI). Factors independently related to PFS were tested using a Cox model and results are presented as hazard ratio. Results: 105 patients with colon cancer and synchronous metastatsis underwent colon surgery prior to chemotherapy (68 males, mean age 64 yrs) when 123 patients were treated first by chemotherapy ± biotherapy (76 males, mean age 63 yrs). By univariate analysis, following factors were significantly associated with PFS: surgery first 25.5 (18.6 - 32.5) vs chemotherapy first 18.3 (14.7 - 21.9) mths p = 0.006; curative surgery: yes 35.7 (29.6 - 41.8) vs no 18.4 (15.6 - 21.2) mths p < 0.001; tumour histological differentiation : no : 13.4 (6.2 - 20.6) vs well : 24.7 (20.4 - 29.1) mths p<0.001; synchronous metastases: liver only 25.5 (20.5 - 30.6) vs peritonea&nodes : 18.4 (10.6 - 26.1) vs pulmonary & other sites : 16.5 (14.7 - 18.3) mths p < 0.0001; need for colonic stent: yes 16.4 (9.3 - 23.5) vs no 23.9 (21.1 - 26.7) months p < 0.0001; antiangiogenic drug: yes 36.6 (28.7 - 44.5) vs no : 20.7 (18.3 - 23.1) p = 0.033. After Cox multivariate analysis five independent factors were found to be associated with PFS. Conclusions: Colon surgery before chemotherapy plus bevacizumab appears to be the more appropriate choice, and associated with longer PFS, especially for those patients with well differentiated tumours and synchronous liver metastases.

[Table: see text]

No significant financial relationships to disclose.

[Not Available]

B. Landi Gastrointestinal stromal tumors (GISTs) are the most frequent intramural mesenchymal tumors of the GI tract, mainly developed in the stomach (65% of cases). Endoscopy is the main diagnostic tool for tumors of moderate diameter (<5cm). Endoscopic ultrasonography (EUS) is the best procedure to differenciate GISTs from other submucosal tumors. Fine-needle aspiration biopsies (FNABs) allow to obtain an histological diagnosis if necessary. Surgery remain the gold standard of treatment for localized GISTs, whereas endoscopic resection is not recommended for these tumors.

HELLP syndrome and placental inflammatory pathology

HELLP syndrome, acronym for hemolysis (H), elevated liver enzymes (EL), and low platelet count (LP), is a multisystemic disease that complicates pregnancy and is considered a severe variant of hypertensive disorders in pregnancy, that causes maternal and perinatal mortality and morbidity. The pathogenesis of HELLP syndrome is not completely understood and the obstetric approach with the induction of delivery is still the only specific therapy in HELLP syndrome. It is well known that the placenta and the incomplete trophoblast invasion of spiral arteries have a central role, but especially in severe pre-eclampsia and in the HELLP syndrome there is a systemic endothelial activation and damage. In this review we emphasize the inflammatory hypothesis and the role of inflammatory cytokines deriving from placenta in pre-eclampsia and HELLP syndrome, also in the light of our recent studies on cytokines pattern.

Cetuximab efficacy and safety in a retrospective cohort of elderly patients with heavily pretreated metastatic colorectal cancer

BACKGROUND

Few data are available from clinical trials for elderly patients receiving cetuximab.

PATIENTS AND METHODS

The clinical data of consecutive patients aged > or =70 years given cetuximab for metastatic CRC were retrospectively captured from hospital pharmacy registries in seven centers.

RESULTS

Fifty-six patients received cetuximab+/-with irinotecan. Median age was 76 years (70-84), 86% of patients were pretreated with fluoropyrimidines, irinotecan and oxaliplatin and 69.6% had documented resistance to irinotecan. Objective response rate was 21% (95% CI: 11-32%). The median progression-free survival was 4.4 months (95% CI: 3.0-5.7 months) and the median overall survival was 16.0 months (95% CI: 13.5-18.5 months). Skin rash occurred in 75% of the patients (11% grade 3) and diarrhea in 80% (20% grades 3-4).

CONCLUSION

Tolerability of cetuximab was acceptable in elderly patients with pretreated metastatic CRC. Efficacy appeared similar to that observed in younger patients.

[Endoscopic approach to GIST]

Gastrointestinal stromal tumors (GISTs) are the most frequent intramural mesenchymal tumors of the GI tract, mainly developed in the stomach (65% of cases). Endoscopy is the main diagnostic tool for tumors of moderate diameter (<5cm). Endoscopic ultrasonography (EUS) is the best procedure to differenciate GISTs from other submucosal tumors. Fine-needle aspiration biopsies (FNABs) allow to obtain an histological diagnosis if necessary. Surgery remain the gold standard of treatment for localized GISTs, whereas endoscopic resection is not recommended for these tumors.

Placental overexpression of transforming growth factor-beta3 in the HELLP syndrome

OBJECTIVE

To evaluate the placental expression of transforming growth factor-beta3 (TGF-beta3) in patients with HELLP syndrome and pre-eclampsia compared to controls, and its correlation to Doppler velocimetry analysis of the utero-placental blood flow.

STUDY DESIGN

Real-time PCR analysis was performed, after cesarean section, in placental samples from 10 women affected by HELLP syndrome, 10 women with pre-eclampsia and 10 controls. Pulsatility indices on Doppler waveform analysis from uterine and umbilical arteries were measured.

RESULTS

The mean TGF-beta3 expression was significantly higher in patients with HELLP syndrome compared with the control group (p < 0.001), and no difference was observed in the pre-eclampsia group. TGF-beta3 expression correlated positively with umbilical PI (p < 0.001).

CONCLUSIONS

TGF-beta3 may play a key role as regulator of a variety of cellular events occurring during HELLP syndrome, high local expression of this growth factor may be responsible for remodeling of the placental structure, which results in the dysfunction of maternal-fetal circulation.

Cetuximab and irinotecan-based chemotherapy as an active and safe treatment option for elderly patients with extensively pre-treated metastatic colorectal cancer

14528

Background: Cetuximab ( C ) has demonstrated activity both as a single agent and in combination with irinotecan (CPT11) in patients (pts) with metastatic colorectal cancer (mCRC) expressing epidermal growth factor receptor (EGFR) refractory to CPT 11 and oxaliplatin based chemotherapy. This European retrospective study explored the tolerability and activity of C combined with CPT 11 in an unselected population of elderly pts with CPT11- refractory mCRC Methods: 67 pts with mCRC aged = 70 yrs were treated with C (400 mg/m2 loading dose over 2 hours, then 250 mg/m2 over 1 hour weekly). C was given alone (2 pts), combined with CPT11 (56 pts) or CPT11 + 5FU-LV as conventional (4 pts) or chronomodulated delivery (5 pts). Treatment was administered as 2nd to 6th line. Primary endpoint was time to tumor progression (TTP). Secondary endpoints were toxicity, objective response rate (RR) (with RECIST Criteria) and overall survival (OS). Results: Median age was 77 yrs (70–84); M/F: 44/23; WHO performance status 0/1/2/unknown: 12/40/11/4; EGFR expression: + in 55 pts, - in 2 pts and unknown in 10 pts; colon/rectum/unknown: 49/14 /4. More frequent toxicities included acneiform skin rash, which occurred in 33 pts (Grade (G) 2: 24 pts, 35%; G3: 9 pts, 13%), diarrhea (G3, 11 pts, 16%; G4, 2 pts, 3%) and neutropenia (G3: 4 pts, 6%; G4: 5 pts, 7%). RR was 23% including 1 complete and 14 partial responses. Disease control rate (RR + stable disease) was 53%. No correlation was found between skin rash and response. Median TTP (intent-to treat) was 4.5 months [95% CI: 3.2 - 5.7]. Median OS was 15 months [12.0–17.9]. Conclusions: The combination of C with CPT11-based chemotherapy resulted in good activity and acceptable tolerability in elderly patients with heavily pre-treated mCRC, comparable to that of the younger patients. This treatment option can be reasonably proposed to the elderly population.

No significant financial relationships to disclose.

Efficacy of recent chemotherapy regimen in advanced small bowel carcinoma

15112

Background: Small bowel carcinoma (SBC) is a rare tumour. Very few data concerning the chemotherapy efficacy are published. The overall survivals previously reported were 8 to 14 months. The aim of the study was to evaluate the efficacy of recent chemotherapy regimen in advanced SBC. Methods: All the consecutive patients treated recently by first line chemotherapy for advanced SBC were included retrospectively in a multicentric study. Clinical and radiological evaluations were performed every 2 or 3 months according to WHO criteria. Chemotherapy was stopped in case of progression, severe toxicity or patient willing. Results: Fifty seven patients (33 men, 24 women), median age 56 years [32–83] treated from 1994 to 2006 in 10 institutions were included. Primary tumours were: duodenum n=35 (61%), jejunum n=14 (25%) and ileum n=8 (14%). Three patients had Crohn disease and one HNPCC syndrome. The tumour were locally advanced in 6 patients (10%), or with metastasis in 51 (90%), synchronous n=35 or metachronous n=16. The mains metastasis sites were peritoneal carcinomatosis in 29, liver in 19 and nodes in 13 patients. Sixteen patients have had an initial R0 surgery and 8 had received, before inclusion, adjuvant chemotherapy. The regimens used in first line were: FOLFOX n=21 (37%), LV5FU2-cisplatine n=13 (23%), LV5FU2 n=12 (21%), FOLFIRI n=10 (17%). Twenty five (44%) patients have had grade 3 or 4 toxicity. A toxic death occurred after a cure of FOLFOX. Chemotherapy was stopped in relation to toxicity in 7 (12%) patients. A dose reduction was done in 15 (26%) patients for a total of 16% of the cures. Tumor was measurable in 42 (73%) pts. A partial response was observed in 13 patients (31%), stabilisation in 14 (33%) and progression in 15 (36%). Thirty six (63%) pts had a second line chemotherapy. Time to treatment failure was 6 [1–21] months in all patients and 7 [2–19], 7 [2–20], 5 [1–21] and 4 [1–10] months according to treatment by FOLFOX, LV5FU2, FOLFIRI or LV5FU2-cisplatine respectively. Overall survival was 11 months [1–36]. Overall survival according to the primary localization were: duodenum: 9 [1–34], jejunum: 18 [3–32], ileum: 15 [4- 36]. Conclusions: Advanced SBC have a bad prognosis. The chemotherapy regimen used in colon cancer did not reach the same efficacy in SBC.

No significant financial relationships to disclose.

Simplified LV5FU2-irinotecan (FOLFIRI) in the first-line therapy of well-differentiated endocrine carcinomas of the duodeno- pancreatic area: Preliminary results of the FFCD 0302 phase II trial with GTE participation

4620

Introduction: Few chemotherapies have been tested in the first-line treatment of endocrine carcinomas. The aim of the study was to evaluate the efficacy of FOLFIRI in the first-line therapy of evolutive, metastatic or locally invasive, well-differentiated endocrine carcinomas of the duodeno-pancreatic area. Methods: To show a 6-month tumoral non-progression (RECIST) rate ≥ 60% (a = 5%), 20 pts had to be included in a phase II, prospective, multicentric trial. Inclusion criteria were : well-differentiated endocrine carcinoma of the duodeno-pancreatic area, functioning or non functioning, with hepatic or extra-hepatic metastases or locally invasive tumor > 50 mm, not resectable; tumoral growth within 6 months; no previous antitumoral therapy except interferon ( = 3 months) or somatostatin analogs; PS 0–2. Treatment administration every 14 days : D1 : irinotecan 180 mg/m2, folinic acid 400 mg/m2, 5 FU 400 mg/m2 bolus; D1-D2 : 5 FU 2,400 mg/m2 in 46 hrs. Evaluation (clinical, radiological, biological) every 3 months. In case of progression during a chemotherapy free-interval following an objective tumoral response, treatment was reintroduced. All analyses were performed in intent to treat. Data cut off was done at July 1st 2006. Results: Between May 2004 and July 2005, 20 pts (13 M, 7 F) were included with median age 57 yrs (37–82). 19 pts had liver metastases and 1 pt had metastatic lymph nodes. 5 tumors were functioning; 2 pts had MEN 1. Median proliferation index was 7% (0–58). All pts were treated and evaluation at 6 months for the primary endpoint was available in 19 pts. The 6-month non-progression rate was 75% (CI 95% = 51–91%,), including 14 stabilization (70%) and 1 partial response (5%). 4 pts had 1 chemotherapy free-interval and 2 pts had 2 with reintroduction of the same chemotherapy regimen. Median number of cycles was 11.5 (1–28). 80% had at least 1 grade 3–4 toxicity and 25% had grade 3–4 hematological toxicity. 10% had grade 3 diarrhoea.. Conclusion: FOLFIRI has an antitumoral effect in the first-line therapy of evolutive well-differentiated pancreatic endocrine carcinomas. Frequency of grade 3–4 toxicities can be explained by length of therapy.

No significant financial relationships to disclose.

FOLFIRI.3, a new regimen combining 5-fluorouracil, folinic acid and irinotecan, for advanced pancreatic cancer: results of an Association des Gastro-Enterologues Oncologues (Gastroenterologist Oncologist Association) multicenter phase II study

BACKGROUND

The purpose of the study was to prospectively evaluate the efficacy and tolerability of the FOLFIRI.3 regimen in patients with unresectable pancreatic adenocarcinoma.

PATIENTS AND METHODS

Chemotherapy-naive patients with histologically proven advanced pancreatic adenocarcinoma were treated with the FOLFIRI.3 regimen, consisting of irinotecan 90 mg/m(2) as a 60-min infusion on day 1, leucovorin 400 mg/m(2) as a 2-h infusion on day 1, followed by 5-fluorouracil (5-FU) 2000 mg/m(2) as a 46-h infusion and irinotecan 90 mg/m(2), repeated on day 3, at the end of the 5-FU infusion, every 2 weeks.

RESULTS

Forty patients were enrolled, of whom 29 (73%) had metastatic disease. A total of 441 cycles were delivered (1-53). Grade 3-4 neutropenia occurred in 35% of the patients, accompanied by fever in two cases. Other relevant grade 3-4 toxic effects were nausea-vomiting (27%) and diarrhea (25%). Grade 2 alopecia occurred in 48% of the patients. There were no treatment-related deaths. The confirmed response rate was 37.5%. Stable disease was observed in 27.5% of the patients. The median progression-free and overall survivals were 5.6 months and 12.1 months, respectively. The 1-year survival rate was 51%.

CONCLUSION

The FOLFIRI.3 regimen seems to be active on advanced pancreatic cancer and to have a manageable toxicity profile. The lack of cross-resistance between FOLFIRI.3 and gemcitabine-based regimens allows efficient second-line therapies.

Survey of cetuximab activity in irinotecan-refractory metastatic colorectal cancer patients

13533

Background: The BOND study demonstrated Cetuximab (Cx) activity in irinotecan-refractory metastatic colorectal cancer (IRMCCR) patients (pts). Cx was approved in Europe early 2004 for this population. The aim of this study was to survey its efficacy in a unselected population of IRMCCR treated in 4 french academic centers. Methods: Data of all IRMCCR pts who had received Cx with or without irinotecan regimen between Jan 2004 and Sept 2005 were included in this survey. Exhaustivity of treated pts was established based on pharmacy registry. Primary end-point was time to tumor progression (TTP). Secondary end-points were overall survival (OS) and tumor response (RECIST). Results: Characteristics of the 76 included IRMCCR pts were : male/female : 44/32; median age 59.5 yrs (range 23 - 79); performance status : 0–1 (59 pts) and 2–3 (17); median number of tumor sites : 2 (1 - 5). The median number of chemotherapy regimens preceeding first Cx administration was 3 (range 1 to 5). At least one local treatment of the metastases (surgical resection and/or radiofrequency ablation) was a part of the strategy before Cx for 39 pts (51.3%). EGFR status was positive in 72 pts and negative in 4. Cx was administered : alone in 4 pts, combined with FOLFIRI in 4 and with irinotecan alone in 68 (89%). 10 pts received only one infusion Cx (early clinical progression : 6; patient decision : 2; early death : 2). Median number of Cx infusions was 10 (range 1 to 60). Median TTP (intent-to-treat) was 3.3 months [IC95% : 2.2–4.6]. Median OS since first-line chemotherapy and first Cx administration were 33.6 months [IC95% : 27.7–41.1] and 7.6 months [IC95% : 5.6–9.5], respectively. Tumor response (full population) was complete response 1.3%, partial response 19.7% (overall response 21%), stable disease 25% (disease control : 46%), progression 37% and not evaluable 17%. Conclusions: This therapeutic survey in a unselected population of IRMCCR are in accordance with the results of the BOND study for TTP, OS and tumor response. (supported by ADEBIOPHARM ER48).

[Table: see text]

A phase II study of FOLFIRI-3 (double infusion of irinotecan combined with LV5FU) after FOLFOX in advanced colorectal cancer patients

In advanced colorectal cancer previously treated with oxaliplatin, efficacy of irinotecan-based chemotherapy is poor and the best regimen is not defined. We designed FOLFIRI-3 and conducted a phase II study to establish its efficacy and safety in advanced colorectal cancer patients previously treated with FOLFOX. FOLFIRI-3 consisted of irinotecan 100 mg m⁻² as a 60-min infusion on day 1, running concurrently with leucovorin 200 mg m⁻² as a 2-h infusion on day 1, followed by 46-h continuous infusion of 5-fluorouracil (5FU) 2000 mg m⁻², and irinotecan 100 mg m⁻² repeated on day 3, at the end of the 5FU infusion, every 2 weeks. Sixty-five patients entered the study. The intent-to-treat objective response rate was 23% (95% CI 13–33%). Disease was stable in 37% of patients, progressed in 26% and was not assessable in 14%. From the start of FOLFIRI-3, median progression-free survival was 4.7 months and median survival 10.5 months. Main toxicities (% of patients) were grade 3–4 diarrhoea 23% and grade 4 neutropenia 11%. FOLFIRI-3 is a promising regimen achieving high response rate and progression-free survival in patients previously treated with FOLFOX with a moderate toxicity.

Video capsule endoscopy for investigation of obscure gastrointestinal bleeding: feasibility, results, and interobserver agreement

BACKGROUND AND STUDY AIMS

The aim of the study was to assess the feasibility, diagnostic yield, and interobserver agreement of capsule endoscopy in the investigation of patients with obscure or occult gastrointestinal bleeding.

PATIENTS AND METHODS

A total of 64 consecutive patients with occult bleeding (31 %) or overt bleeding (69 %) were assessed using capsule endoscopy after negative upper and lower endoscopy and small-bowel radiology. The quality of visualization of the small-bowel mucosa was scored from 1 (poor) to 4 (excellent). Thirty video capsule recordings with normal or abnormal findings were blindly assessed by four independent endoscopists. Interobserver agreement was evaluated using the kappa index.

RESULTS

The small bowel was completely visualized in 57/64 patients (89 %). Incomplete small-bowel transit was most commonly due to prolonged gastric retention (five patients). The mucosa visualization scores (means) for the proximal, middle, and distal thirds of the small bowel were 3.7, 3.3, and 2.2 respectively. Visualization of the distal ileum was good (> or = 3) in 38 % and a bleeding site was found in 45 % of patients. Push-enteroscopy was also performed in 56 patients. The results of the two techniques were similar in 37 patients, capsule endoscopy was superior in 12 patients, and push-enteroscopy was superior in seven patients. Interobserver agreement was good for bleeding and for angiodysplasia, but poor for ulcers and tumors. Mean interobserver agreement was better among experienced endoscopists than among junior endoscopists.

CONCLUSIONS

Capsule endoscopy allowed the whole small intestine to be explored in 89 % of patients, with good visualization of the mucosa, except distally. Interobserver agreement was better among the experienced endoscopists and was better for red-colored abnormalities (bleeding and angiodysplasia) than for ulcers and tumors.

Push-and-pull enteroscopy in the small bowel using the double-balloon technique: results of a prospective European multicenter study

BACKGROUND AND STUDY AIMS

The aim of this study was to evaluate the feasibility, safety, and clinical impact of push-and-pull enteroscopy (PPE) in patients with suspected or documented small-bowel diseases, in a prospective multicenter trial in three European medical centers.

PATIENTS AND METHODS

A total of 100 patients (mean age 56 +/- 16 years; range 13 - 90) were included at the three institutions between July and November 2004. The leading symptoms were: acute recurrent or chronic gastrointestinal bleeding (n = 64), polyposis syndrome (n = 8), chronic abdominal pain (n = 7), chronic diarrhea (n = 7), and others (n = 14).

RESULTS

No major PPE-associated complications such as perforation, bleeding, or relevant injury to the small-bowel tissue or mesentery were encountered. Minor complications occurred in 12 %. The mean time required to carry out the procedure from the oral and anal approaches was 75 +/- 19 min (32 - 150 min). The average insertion depths into the small bowel were 200 +/- 70 cm per PPE session (220 +/- 90 cm with the oral approach and 130 +/- 80 cm with the anal approach). The average radiation exposure (including diagnostic and therapeutic interventions) was 2.1 +/- 2.4 min and 155 +/- 159 dGy/cm2. PPE was fully diagnostic in 72 % of cases. The majority of the patients (34 %) were suffering from angiodysplasias; ulcerations and erosions of various etiologies were seen in 16 %, and polyps and tumors in 13 %. The PPE findings played a role in the subsequent treatment in 62 % of the patients. Endoscopic treatments, including argon plasma coagulation, polypectomy, dilation, and foreign-body extraction, were carried out in 42 %. Medical treatment was given in 12 %, and patients were referred for surgery in 8 % of cases.

CONCLUSIONS

This prospective analysis shows that PPE is safe and has a high diagnostic and therapeutic yield in patients with suspected or known small-bowel disease.

Long-term outcome of patients with gastrointestinal bleeding of obscure origin explored by push enteroscopy

BACKGROUND AND STUDY AIMS

Little is known of the long-term outcome in patients with gastrointestinal bleeding of obscure origin, who undergo investigation by means of push enteroscopy. The aim of this study was to assess the rate of recurrent bleeding and its predictive factors in patients with gastrointestinal bleeding of obscure origin, after exploration by push enteroscopy.

PATIENTS AND METHODS

105 patients with gastrointestinal bleeding of obscure origin (iron-deficiency anemia: n = 56; overt bleeding: n = 49) underwent exploration by push enteroscopy from December 1994 to December 1998. They were classified into three groups according to enteroscopy findings: no lesion found (group A; 56 patients), arteriovenous malformations (group B; 18 patients), and other gastrointestinal lesions (group C; 31 patients). Actuarial rates of rebleeding during follow-up were calculated and factors associated with rebleeding were assessed by means of univariate and multivariate analysis.

RESULTS

Follow-up data were obtained for 101 patients (96 %). The mean follow-up was 29 months (6 - 54 months). The 2-year actuarial rate of rebleeding was 31 % in the overall population, and 27.6 %, 56 % and 24 % in groups A, B, and C, respectively (P = 0.13). The number of previous bleeding episodes and the number of packed red cell units transfused were two independent factors predictive of recurrent bleeding. The modality of recurrent bleeding (anemia or overt bleeding) was similar to that of the initial episode in 94 % of cases. In group A, a gastrointestinal lesion was found after rebleeding in one of the 12 patients with iron-deficiency anemia, and in four of the five patients with overt bleeding.

CONCLUSION

Recurrent bleeding occurs in about one-third of patients who undergo investigation by push enteroscopy for gastrointestinal bleeding of obscure origin, with a trend towards more frequent rebleeding in patients with arteriovenous malformations. Frequent previous bleeding episodes and transfusion requirements are predictive of recurrent bleeding.

Is push enteroscopy useful in patients with malabsorption of unclear origin?

OBJECTIVE

The aim of this study was to determine the diagnostic value of push enteroscopy in patients with chronic diarrhea and malabsorption of unclear origin.

METHODS

From January, 1997, to September, 1999, 16 consecutive patients with chronic diarrhea and biological signs of intestinal malabsorption but no evidence of celiac disease were explored by push enteroscopy. Previous duodenal histological findings had been normal in seven patients and abnormal but inconclusive in nine patients. Endoscopic and histological findings in the duodenum and in the jejunum were compared.

RESULTS

Push enteroscopy with jejunal biopsy yielded a diagnosis in comparison with duodenal biopsy in two of 16 (12%) patients, respectively, in two of the nine (22%) patients with abnormal but inconclusive findings on duodenal biopsy, and none of the seven patients with normal duodenal histology. In the two patients in whom jejunal biopsy had diagnostic value but duodenal biopsy did not, the final diagnoses were invasive intestinal lymphoma and microsporidiosis.

CONCLUSION

Push enteroscopy had diagnostic value in only 12% of patients with malabsorption of unclear origin, all of whom had had abnormal but inconclusive duodenal histological findings. Push enteroscopy with jejunal biopsy appears to have limited diagnostic value in patients with chronic diarrhea and malabsorption, especially when duodenal biopsies are histologically normal.

Carcinoembryonic gene member 2 mRNA expression as a marker to detect circulating enterocytes in the blood of colorectal cancer patients

BACKGROUND

The aim of this study was to report our experience with a new molecular tool to detect circulating enterocytes in the blood of patients with colorectal cancer.

METHODS

The study included 193 individuals: 78 patients with colorectal cancer and 115 controls composed of patients with benign colorectal diseases (n = 16), patients with noncolorectal cancer (n = 31), healthy individuals (n = 62), and healthy bone marrow transplantation donors (n = 6). A nested reverse transcriptase-polymerase chain reaction with specific primers for the carcinoembryonic gene member 2 (CGM2) was used to detect circulating enterocytes in the peripheral blood of 78 patients with colorectal cancer. The blood (n = 109) or the bone marrow (n = 6) of the 115 controls was studied to test the absence of CGM2 illegitimate transcription in nucleated blood cells and nucleated blood cell progenitors. The assay sensitivity was effective in detecting 1 CGM2-positive cell per 10(6) nucleated blood cells.

RESULTS

Fifty-nine percent (46/78) of patients with colorectal cancer were found positive whereas all negative controls remained negative. Positivity rates were 38% (3/8) in Dukes' A classification, 43% (9/21) in Dukes' B, 77% (23/30) in Dukes' C, and 58% (11/19) in Dukes' D.

CONCLUSIONS

The clinical significance of enterocyte detection in the blood of colorectal cancer patients by means of this CGM2 messenger RNA assay needs further evaluation.

Phase II trial of bimonthly leucovorin, 5-fluorouracil and gemcitabine for advanced pancreatic adenocarcinoma (FOLFUGEM)

BACKGROUND

Gemcitabine alone or 5-fluorouracil (5-FU) according to several schedules are used for palliation of metastatic and locally advanced (LA) pancreatic adenocarcinoma. This study was designed to test the efficacy of the leucovorin 5-FU and gemcitabine combination.

PATIENTS AND METHODS

This phase II trial combined a simplified bimonthly LV5FU2 with gemcitabine: leucovorin 400 mg/m2 in a two-hour infusion, followed by 5-fluorouracil 400 mg/m2 bolus and 2 or 3 g/m2 continuous infusion over 46 hours; gemcitabine 1 g/m2 was infused over 30 min on day 3 after 5-FU. Treatment was repeated every two weeks. Gemcitabine dose could be increased (250 mg/m2 every two cycles up to 1500 mg/m2) in the absence of NCI-CTC toxicity > 2.

RESULTS

Among the 62 patients included in this study, 22 had LA and 40 had metastatic disease. Objective response rate for the 54 patients with measurable disease was 25.9% (95% confidence interval (CI): 14%-37.8%) and 22.6% (95% CI: 12%-33.2%) in the intent-to-treat population: the clinical benefit rate for the 59 assessable patients was 49.2%. Median progression-free survival and median overall survival were 4.8 and 9 months, respectively, with 32.3% of patients alive at 1 year. The most frequent toxicity (grade 3-4) was neutropenia (56.5%) usually asymptomatic (1.1% febrile neutropenia), but requiring decreases of 5-FU and gemcitabine doses. Unexpected complete alopecia occurred in 97% of patients.

CONCLUSIONS

Palliative effects, response rate and survival observed in this multicenter study seem to be superior to those obtained with gemcitabine or 5-FU alone, despite a limiting hematological toxicity.

Biliary varices on endoscopic ultrasonography: clinical presentation and outcome

BACKGROUND AND STUDY AIMS

Bile duct varices are not a well-recognized feature of portal venous obstruction. The aim of the present study was to describe the clinical and endosonographic features of biliary involvement in patients with extrahepatic portal venous obstruction (EPVO).

PATIENTS AND METHODS

A retrospective study was conducted of the clinical features, outcome, and endosonographic findings (using Olympus EUM-3 or EUM-20 probes) in 21 patients with EPVO and endosonographic features of biliary varices. Biliary varices were defined as multiple, large, serpiginous, anechoic vascular channels in and/or surrounding the extrahepatic biliary tracts.

RESULTS

Biliary varices have not previously been visible using conventional imaging methods (computed tomography and ultrasonography). They were identified using EUS in the wall of the common bile duct in 16 patients (76%), surrounding the common bile duct (CBD) in 11 patients (52%), and in the gallbladder in nine (43%). The varices were the cause of obstructive jaundice in three of the 21 patients (14%), but only when they were in the wall of the CBD. Two of these patients were treated using portosystemic shunting, and the other received a biliary endoprosthesis. The EUS examination also provided evidence of unrecognized pancreatic or biliary tumors in three other patients with EPVO of undetermined origin.

CONCLUSIONS

EUS can serve to diagnose biliary varices in patients with EPVO and jaundice. Although biliary varices are mainly asymptomatic, they may cause obstructive jaundice when they are located in the wall of the CBD. EUS can also detect unrecognized malignant tumors in patients with EPVO of undetermined origin.

Prospective multicenter study comparing a standard reusable sphincterotome with a disposable triple-lumen sphincterotome

BACKGROUND

Few data are available on the comparative performance of different types of sphincterotome. The aim of this study was to compare the efficacy of endoscopic sphincterotomy performed with either a reusable, single-lumen sphincterotome or a disposable triple-lumen instrument.

METHODS

Seventy-seven consecutive adults requiring endoscopic sphincterotomy were prospectively and randomly assigned treatment with either a standard reusable single-lumen sphincterotome (group A, n = 38) or a disposable triple-lumen sphincterotome with a guidewire (group B, n = 39). The success rate, complications, and cost of the procedure per patient were compared.

RESULTS

Deep cannulation was successful in 87% of cases in each group and sphincterotomy was achieved in 76% and 84% of cases in group A and B, respectively (NS). In the endoscopists' opinion the two instruments performed almost equally well. Twelve procedure-related complications occurred: 5 (all hemorrhages) in group A and 7 (1 hemorrhage, 4 cases of pancreatitis and 2 of cholangitis) in group B (NS). Eight reusable sphincterotomes were used with a cost of $61 per patient, compared with 39 disposable sphincterotomes with a cost of $241 per patient (p = 0.02).

CONCLUSIONS

A standard reusable sphincterotome is satisfactory for most endoscopic sphincterotomies, and yields a substantial cost savings without compromising the success or safety of the procedure.

[Pretherapeutic endosonography in rectal adenocarcinoma]

The advent of transrectal ultrasonography has contributed to improving therapeutic management of cancer of the rectum. The 7.5 MHz transrectal probe evidences five tissue layers in the rectal wall. The 10-12.5 MHz probe can visualize seven layers. Transrectal ultrasonography can also be used to explore the perirectal environment and detect possible nodes. Echographically, the tumor is seen as an hypoechogenic mass invading the rectal wall outwardly, disorganizing the wall structures. Parietal recurrence is seen as a hypoechogenic heterogeneous thickening. Ultrasonographic surveillance can be proposed for operable patients with a high risk of recurrence. Cautious interpretation is required due to the known limitations of transrectal ultrasonography. Truly invaded nodes may not be seen due to their small size (less than 2-3 mm) or their localization far from the probe (false negatives). Transrectal ultrasonography provides important information for therapeutic decision making in terms of surgical access and/or indications for possible adjuvant therapy. Transanal resection may also be ruled out if there are perirectal nodes. Patients may also be selected for preoperative radiotherapy, possibly associated with chemotherapy.

Endosonographic features predictive of benign and malignant gastrointestinal stromal cell tumours

BACKGROUND/AIM

Some endoscopic ultrasonographic (EUS) features have been reported to be suggestive of malignancy in gastrointestinal stromal cell tumours (SCTs). The aim of this study was to assess the predictive value of these features for malignancy.

METHODS

A total of 56 histologically proven cases of SCT studied by EUS between 1989 and 1996 were reviewed. There were 42 gastric tumours, 12 oesophageal tumours, and two rectal tumours. The tumours were divided into two groups: (a) benign SCT, comprising benign leiomyoma (n = 34); (b) malignant or borderline SCT (n = 22), comprising leiomyosarcoma (n = 9), leiomyoblastoma (n = 9), and leiomyoma of uncertain malignant potential (n = 4). The main EUS features recorded were tumour size, ulceration, echo pattern, cystic spaces, extraluminal margins, and lymph nodes with a malignant pattern. The two groups were compared by univariate and multivariate analysis.

RESULTS

Irregular extraluminal margins, cystic spaces, and lymph nodes with a malignant pattern were most predictive of malignant or borderline SCT. Pairwise combinations of the three features had a specificity and positive predictive value of 100% for malignant or borderline SCT, but a sensitivity of only 23%. The presence of at least one of these three criteria had 91% sensitivity, 88% specificity, and 83% predictive positive value. In multivariate analysis, cystic spaces and irregular margins were the only two features independently predictive of malignant potential. The features most predictive of benign SCTs were regular margins, tumour size < or = 30 mm, and a homogeneous echo pattern. When the three features were combined, histology confirmed a benign SCT in all cases.

CONCLUSIONS

The combined presence of two out of three EUS features (irregular extraluminal margins, cystic spaces, and lymph nodes with a malignant pattern) had a positive predictive value of 100% for malignant or borderline gastrointestinal SCT. Tumours less than 30 mm in diameter with regular margins and a homogeneous echo pattern are usually benign.

Metastatic jejunal VIPoma: beneficial effect of combination therapy with interferon-alpha and 5-fluorouracil

The VIPoma syndrome is rare. It is usually caused by a neuroendocrine tumor located in the pancreas. Somatostatin analogs and interferon-a can be helpful in the symptomatic control of the disease, but the efficacy of chemotherapy in metastatic disease is limited. We report the case of a 32-yr-old patient who had a primary intestinal VIPoma with peritoneal carcinomatosis and hepatic metastases. Somatostatin analogs and conventional chemotherapy regimens were not effective on VIPoma syndrome and tumor progression. The combination of 5- fluorouracil and interferon-alpha was associated with a major clinical improvement and tumor regression. Further investigations should evaluate the place of such a combination as a first line treatment for patients with metastatic neuroendocrine tumors.

Right colonic involvement is associated with severe forms of ischemic colitis and occurs frequently in patients with chronic renal failure requiring hemodialysis

OBJECTIVE

The aim of this study was to identify factors associated with severe outcome in patients with ischemic colitis.

METHODS

The files of 60 consecutive inpatients (34 women, 26 men, mean age 67 yr) with ischemic colitis were reviewed. The following data were analyzed: age, sex, smoking, medications, history of cardiovascular disease, metabolic disease, chronic renal failure and hemodialysis, the time elapsed between the first symptoms and the diagnosis, and the site and extension of their colonic involvement. Patients were divided into two groups according to outcome: those with severe disease, including those who died from ischemic colitis (n = 3) or who required surgical resection (n = 21); and those with mild forms of colitis who were treated successfully without surgery (n = 36). The two groups were compared by means of univariate and multivariate analysis to identify factors associated with unfavorable outcomes. Only patients who had a complete examination of the colon (n = 51) were entered into the statistical analysis.

RESULTS

By univariate analysis, chronic renal failure (p = 0.03), hemodialysis (p = 0.01), short delay between symptoms and diagnosis (p = 0.01), and right colonic involvement (p = 0.002) were significantly more common in the patients with severe colitis. By logistic regression, right colonic involvement was the only factor independently associated with severity (p = 0.01). Right-sided lesions were present in 82% of patients on dialysis but in only 26% of patients not on dialysis (p = 0.0005).

CONCLUSIONS

Right colonic involvement is associated with severe forms of ischemic colitis and occurs frequently in patients with chronic renal failure requiring hemodialysis.

Push enteroscopy in celiac sprue and refractory sprue

BACKGROUND

The aim of this study was to determine in patients with sprue whether jejunal endoscopy improves the diagnostic yield or provides information that may modify management, when compared with evaluation limited to the duodenum.

METHODS

From January 1994 to June 1998, a total of 31 patients (6 men, 25 women, mean age 41 years) were prospectively evaluated by push enteroscopy. They were divided into two groups: (1) celiac disease at different stages of activity (n = 23) and (2) refractory sprue (n = 8). The endoscopic and histologic findings in the duodenum and in the jejunum were compared.

RESULTS

Celiac disease: In 19 patients, endoscopic and histologic findings in the duodenum and jejunum were similar; in four patients villous atrophy was more severe in the duodenum than in the jejunum. Refractory sprue: In 5 of 8 patients, enteroscopy revealed ulcerative jejunitis, whereas ulcerations were found in the duodenum in only one case.

CONCLUSION

In refractory sprue, push enteroscopy with jejunal biopsies was of diagnostic value in 50% of cases demonstrating ulcerative jejunitis, whereas it did not modify the management of patients with responsive celiac disease.

Small bowel metastases from primary carcinoma of the lung: clinical findings and outcome

OBJECTIVE

Symptomatic small bowel metastases from primary carcinoma of the lung have been rarely reported. The aim of this study was to describe clinical presentation and outcome in a series of patients.

METHODS

Between 1984 and 1996, 1544 patients with lung cancer were referred to our institution for surgery and 1399 were operated on. Seven of them developed a symptomatic small bowel metastasis. Clinical, radiological, and pathology records were reviewed.

RESULTS

In 6 of 7 patients, the lung cancer was previously operated on from 0.5 to 24 months before the diagnosis of small bowel metastasis. In 1 patient, the primary tumor was diagnosed after small bowel metastasis resection. Clinical symptoms at presentation were acute peritonitis in 2 patients, progressive digestive obstruction in 3, and gastrointestinal bleeding in 2. The diagnosis was suspected on abdominal ultrasonography in 2 cases, and small bowel radiography in 3 cases. It was confirmed either by computed tomographic scan or by push enteroscopy. All patients underwent operation (intestinal resection in 6 and bypass in 1) with no postoperative death. Small bowel metastases were located in the jejunum in 2 patients, in the ileum in 3, and in both sites in 2. Histological features of the metastases were identical to the primary tumor: squamous cell carcinoma (n = 3), undifferentiated large cell carcinoma (n = 2), adenosquamous carcinoma (n = 1), and adenocarcinoma (n = 1). In 6 patients, small bowel metastases were associated with other metastatic sites. Six patients died within 8 months after metastasis resection. One patient was alive 22 months after bowel resection.

CONCLUSIONS

Symptomatic small bowel metastases can occur early in the course of lung cancer. Resection should be considered as the best palliative treatment to prevent bowel obstruction or peritonitis.

Simple clinical assessment of colonic response to food

The colonic response to food (CRF) is an integrated function of the colon that has been poorly studied in clinical practice. This study describes a new method to measure it, based on the progress of radio-opaque markers, and shows the results in healthy subjects and in patients with irritable bowel syndrome (IBS). Thirty healthy subjects and 43 patients suffering from IBS were studied. Two studies of colonic transit time (CTT), at rest and after eating a standard test meal, were performed. CRF was quantified by calculating the variation in number of markers in each zone of interest of the large bowel using X-ray films of the abdomen taken before and after eating. The results were as follows: (1) CRF is characterised by caudal propulsion of the colonic contents in the two groups. In controls, there is emptying of the cecum-ascending colon region and filling of the distal large bowel. In IBS patients, only emptying of the left transverse colon and the splenic flexure is found. (2) IBS patients have a delayed CTT because of slowing in the right and left colon, and this is both before and after a meal. The determination of the movements of markers after eating is a simple method that is useful in clinical practice to evaluate CRF.

[Dieulafoy colonic ulcer. A rare cause of lower gastrointestinal hemorrhage]

Dieulafoy's disease is an unusual cause of gastrointestinal hemorrhage, reported to account for less than 2% of acute gastrointestinal bleeding episodes. Bleeding occurs from a defect in an unusually large submucosal artery, through a minute mucosal erosion. Endoscopic diagnosis is sometimes difficult, but primary endoscopic therapy may be successful and should be attempted. In most cases the lesion is found in the proximal stomach. Sixteen cases of Dieulafoy's lesion located in the colon have been reported in the literature but only nine have been confirmed by histology. We present the case of a 63 year-old male with Dieulafoy's lesion of the transverse colon which was diagnosed by endoscopy and confirmed by histology.