High hand grip strength is a significant risk factor and a useful predictor of postoperative pancreatic fistula following pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) is one of the most critical complications of pancreaticoduodenectomy (PD). Studies on predictive factors for POPF that can be identified preoperatively are limited. Recent reports have highlighted the association between the preoperative nutritional status, including sarcopenia, and postoperative complications. We examined preoperative risk factors for POPF after PD, focusing on nutritional indicators.

METHODS

A total of 153 consecutive patients who underwent PD at our institution were enrolled in this study. Preoperative nutritional parameters, including hand grip strength (HGS) and skeletal muscle mass as components of sarcopenia, were incorporated into the analysis. POPFs were categorized according to the International Study Group of Pancreatic Fistula (ISGPF) definition as biochemical (grade A) or clinically relevant (CR-POPF; grades B and C).

RESULTS

Thirty-seven of the 153 patients (24.1%) fulfilled the ISGPF definition of CR-POPF postoperatively. In the univariate analysis, the incidence of CR-POPF was associated with male sex, non-pancreatic tumor diseases, a high body mass index, a high HGS and a high skeletal muscle mass index. In the multivariate analysis, non-pancreatic tumor diseases and an HGS ≥23.0 kg were selected as independent risk factors for CR-POPF (P <0.05).

CONCLUSIONS

A high HGS, a screening tool for sarcopenia, was a risk factor for CR-POPF. It can accurately serve as a useful predictor of POPF risk in patients undergoing PD. These results highlight the potential of sarcopenia to reduce the incidence of POPF and highlight the need to clarify the mechanism of POPF occurrence.

Total Neoadjuvant Chemotherapy in Rectal Cancer: Current Facts and Future Strategies

Despite preoperative chemoradiotherapy (CRT) and total mesorectal excision improving the local control for locally advanced rectal cancer (LARC), oncologic outcomes and survival were not significantly improved because the main prognostic factor is distant metastasis. Thus, total neoadjuvant chemotherapy (TNT) as a novel approach has been proposed to improve chemotolerance. Since the first randomized phase II trial of TNT versus standard CRT demonstrated in 2012, many prospective and retrospective studies have been published. The initial consensus from TNT studies was that pathological complete response, pathological response of the main tumor, and local control are more favorable at TNT than at CRT. Furthermore, recent studies such as the PAPIDO trial and PRODIGE 23 trial made a major breakthrough of the treatment of TNT, showing that TNT improves the disease-free survival compared to standard treatment with long-course CRT. In addition, several innovative findings of TNT were clarified by prospective phase II trial. In this review, we summarize the most recent advances in TNT based on the findings of pivotal clinical trials for patients with LARC.

Erratum forTotal Neoadjuvant Chemotherapy in Rectal Cancer: Current Facts and Future Strategies

[This corrects the article DOI: 10.23922/jarc.2022-060.].

[A Case of Long-Term Survival with S-1/Cisplatin for Liver Hilum Lymph Node Metastasis of Anal Canal Squamous Cell Carcinoma after Chemoradiotherapy]

A 70-year-old woman was admitted to a local hospital because of anal pain during defecation. Anoscopy revealed an anal mass lesion, and the patient was referred to our hospital. Colonoscopy revealed an anal canal tumor with ulceration, and biopsy showed squamous cell carcinoma. The patient was treated with chemoradiotherapy(chemotherapy with capecitabine plus mitomycin C and 54 Gy radiation in the anal region)and achieved complete response. However, metastatic recurrence was detected in a lymph node in the hepatic hilar region. We administered an S-1/CDDP combination chemotherapy (5 courses). For 3 years and 5 months since the initial treatment, the patient survived with no signs of recurrence. We report a rare case of long-term survival with S-1/CDDP for distant metastasis of anal canal squamous cell carcinoma after chemoradiotherapy.

[Two Cases of Elderly Patients with Giant Intrahepatic Cholangiocarcinoma Treated with Multidisciplinary Therapy including Ablation Therapy]

Case 1 consisted of an 86-year-old male diagnosed with intrahepatic cholangiocarcinoma(ICC), approximately 11 cm in diameter, at segment S7/8 of the liver. A total of 4 percutaneous radiofrequency ablations(PRFA)and 3 hepatic arterial infusion chemotherapies(HAIC)of 5-FU were performed. He died after developing lung metastases 27 months after the initial treatment. Case 2 was an 85-year-old female diagnosed with ICC, 8 cm in diameter, at the posterior segment of the liver, with lymph node metastasis. She underwent HAIC of 5-FU and S-1 as well as gemcitabine-based systemic chemotherapy. The main tumor developed 10 months after the initial treatment, and PRFAs were subsequently performed twice for the main lesion. Although the tumor markers gradually decreased, she died of jaundice 33 months after the initial treatment. As one of the multidisciplinary therapies for the giant ICC, ablation therapy may be safe and effective in elderly patients.

[Clinical Study of Peritoneovenous Shunt for Patients with Refractory Ascites Accompanied with Hepatocellular Carcinoma]

BACKGROUND

Hepatic ascites may cause a variety of symptoms and may progress deterioration of quality of life. Peritoneovenous shunt(PV shunt)is technically feasible and useful for the treating of refractory ascites, but sometimes it can be associated with fatal complications. This retrospective study aimed to investigate the effect of PV shunt for patients with refractory ascites, including hepatocellular carcinoma(HCC)patients.

SUBJECTS

Between January 2010 and December 2021, we retrospectively analyzed 54 consecutive patients(including 35 HCC patients)with refractory ascites who underwent PV shunt at our institute.

RESULTS

Body weight loss after surgery was observed in 39 of the 54 cases, and eGFR improved in 34 cases. There were 17(31.5%)in-hospital deaths. Cases with present of portal vein tumor thrombus, Child-Pugh classification C, ALBI score≥-1.12, or serum total bilirubin≥1.7 mg/dL were significantly higher in hospital-death group than in the discharged from the hospital group.

CONCLUSIONS

PV shunt for HCC patients with refractory ascites may be effective for improvement of renal function and symptoms. However, indications for PV shunt should be carefully considered for high-risk patients with adequate preoperative evaluation.

[A Rapid Clinical Course of Pulmonary Embolism Associated with Gallbladder Mucinous Carcinoma]

A 51-year-old woman with edema of the lower extremities and exertional dyspnea was admitted to our hospital. Enhanced CT revealed thrombi of the pulmonary artery and a gallbladder tumor. After anticoagulation therapy was started on her, anemia and jaundice progressed; thus, endoscopic retrograde cholangiopancreatography(ERCP)was performed on suspicion of bleeding from a gallbladder tumor. We performed cholecystectomy in emergency to control the anemia due to hemorrhage. Oxygenation suddenly worsened intraoperatively, maintaining her blood pressure became difficult, and the patient decompensated. The histopathological diagnosis was gallbladder mucinous carcinoma with severe lymphatic invasion. Although an autopsy was not performed, pulmonary artery embolism derived from a tumor embolus was the suspected cause of the sudden change of the clinical course.

[Clinical Efficacy of Recombinant Human Thrombomodulin for Surgical Patients with Disseminated Intravascular Coagulation Associated with Oncologic Emergency]

AIM

We evaluated the clinical efficacy of recombinant human thrombomodulin(rTM)for surgical patients with disseminated intravascular coagulation syndrome(DIC)associated with an oncologic emergency(OE).

SUBJECTS AND METHODS

Thirteen patients who underwent surgery for OE complicated with DIC and were treated with rTM in our institution were evaluated. We retrospectively analyzed the clinical changes of parameters in white blood cell count(WBC), platelet count, CRP, PT-INR and DIC scores after the rTM treatment.

RESULTS

The average length of the days using rTM was 4.7 for 12 patients, excluding one who died within 30 days after surgery. Nine of 12 patients(75%)had DIC scores of less than 3 after the rTM treatment. WBC tended to decrease after the rTM treatment, without statistical difference. However, CRP, platelet count, PT-INR and DIC scores were significantly improved after the rTM treatment(p<0.05).

CONCLUSIONS

rTM may be useful in the treatment of DIC for surgical OE patients.

Characteristics and outcome of suspected cerebrovascular disease in dogs: 66 cases (2009-2016)

OBJECTIVES

To characterise the clinical signs of suspected cerebrovascular disease in dogs.

MATERIALS AND METHODS

Medical records of one hospital were searched from November 2009 to December 2016 for dogs that suffered of cerebrovascular disease. We diagnosed cerebrovascular disease based on acute onset, clinical signs and magnetic resonance imaging findings. The medical history, clinical signs, concurrent disease, area of infarction, cerebrospinal fluid results, month at onset and outcome were investigated in the cerebrovascular disease group and in a control group (dogs with brain disorders other than cerebrovascular disease).

RESULTS

A total of 122 CVD cases were extracted from the 5312 patients that visited during the study period. Of these 122 cases, 66 (1.2%) matched the subject selection criteria of our study and were included in the analysis. Forebrain infarction was observed in 51 of 66 cases, of which 24 (47.1%) suffered from seizures. The number of dogs diagnosed with cerebrovascular disease was disproportionately high in August (nine of 59 cases) and December (13 of 59 cases). In the outcome survey, deterioration was observed in 11 of 55 cases.

CLINICAL SIGNIFICANCE

Seizure is an important clinical sign of cerebrovascular disease in dogs. There was a significant seasonal variation in the number of dogs diagnosed with cerebrovascular disease in Japan. Clinical features observed in this report differ from those of previous reports and highlight the need for additional research in this area.

[A Resected Case of Metachronous Solitary Metastasis of Jejunum after Surgery of Triple Colon Cancers]

A 68-year-old man underwent partial colectomy and double-barrel colostomy for an obstructive colon cancer of the splenic flexure at another hospital 10 years before. He was referred to us with an examination of anemia pointed out in human dock. Lower gastrointestinal endoscopy revealed the tumor occupied the remnant descending colon. We performed remnant left hemicolectomy and diagnosed as triple colon cancers. Six months after the initial operation, he was admitted to us with the chief complaints of abdominal fulness and vomit. Abdominal CT and radiologic enteroclysis after decompression used the ileus tube revealed complete stenosis at the small intestine. We performed surgery with a suspicion of obstruction of the small intestine. The tumor, 5 cm in diameter, occupied the jejunum was detected, and partial resection of the jejunum was performed. Histologically, the tumor was diagnosed as solitary metastasis of jejunum.

[Hepatectomy for Intrahepatic Combined Hepatocellular Carcinoma Recurrence in a Hemophilia a Patient with Human Immunodeficiency Virus and Hepatitis C Virus-A Case Report]

A 40's Japanese man had a history of blood transfusion and administration of treatment coagulation factors for hemophilia A since he was 6 years old. He has been on IFN treatment for hepatitis C since he was 14 years old. Lastly, he has been undergoing HAART therapy for human immunodeficiency virus infection since he was 18 years old. Three years ago, he underwent partial hepatectomy for a tumor located in segment 8 of his liver and was diagnosed with combined hepatocellular carcinoma(CHC). Two years and 7 months after the operation, 2 intrahepatic recurrences were detected in the left lobe. He was referred to our hospital to undergo curative resection, and we performed a left lobectomy of the liver for the CHC recurrences. Perioperatively, supplemental factor Ⅷ was administered via APTT. Its activity was used as an index. Postoperatively, the patient was well, was discharged 13 days after surgery, and remained recurrence-free for 4 months.

Phase II study of S-1-based sequential combination chemotherapy including oxaliplatin plus bevacizumab and irinotecan with or without cetuximab for metastatic colorectal cancer: the SOBIC trial

BACKGROUND

Fluorouracil and leucovorin combined with oxaliplatin or irinotecan plus bevacizumab (Bmab) or cetuximab (Cmab) are now widely accepted treatment options as first-line or second-line chemotherapy for metastatic colorectal cancer (mCRC). Sequential chemotherapy with oral 5-FU backbone for mCRC without using central venous ports is beneficial for both patients and physicians. We designed the SOBIC trial to validate the effectiveness of the first- and second-line oral combination chemotherapy for mCRC.

PATIENTS AND METHODS

From May 2010 through March 2013, 52 patients were enrolled from 47 institutions in the Hyogo Colorectal Cancer Surgery Group. First-line chemotherapy was S-1 + oxaliplatin (SOX) plus Bmab, and second-line chemotherapy after first-line failure was irinotecan + S-1 (IRIS) + Cmab, IRIS + Bmab, or IRIS based on the KRAS status.

RESULTS

The 50 finally included patients received first-line chemotherapy. Second-line therapy was administered to 20 patients (40%): 12 patients received IRIS + Cmab and 8 patients received IRIS + Bmab. The median follow-up period was 48.6 months (range 35-67 months). The median second progression-free survival was 24.2 months (95% confidence interval [CI] 17.7-35.2). The response rate after first- and second-line chemotherapy was 46.7% and 15%, respectively. The median overall survival was 35.2 months (95% CI: 27.8 to not reached). The main grade 3-4 adverse events were sensory neuropathy (18%) and fatigue (10%). There were no treatment-related deaths.

CONCLUSION

Sequential S-1-based combination regimens including oxaliplatin, irinotecan, Bmab, and Cmab were beneficial for patients with mCRC.

S-1, Oxaliplatin, Nab-paclitaxel and Itraconazole for Conversion Surgery for Advanced or Recurrent Gastric Cancer

AIM

To evaluate the efficacy of chemotherapy with itraconazole for advanced or recurrent gastric cancer.

PATIENTS AND METHODS

Patients with human epidermal growth factor receptor 2 (HER2) negative unresectable gastric cancer referred to our hospital were included. The regimen comprised 160 mg/m² nab-paclitaxel i.v. and 100 mg/m² oxaliplatin i.v. on day 1, 60 mg/m² S-1 orally on days 1-3, and 400 mg itraconazole orally on days -2 to 2, repeated every 2 weeks for 6-8 cycles.

RESULTS

Twenty-three patients aged 40-80 years (median age=68 years) were enrolled, of whom 21 had stomach cancer and two gastroesophageal junction cancer. Regarding stage, two, one, and 20 patients had stage IIIA, IIIB, and IV, respectively. Among patients with liver metastases, 2/10 had simultaneous lung metastases. Nine patients had peritoneal dissemination, and five patients with stage IV disease developed recurrence after primary surgery followed by adjuvant S-1. The other 18 patients had no history of surgery or chemotherapy. The response rate was 70% (complete response in two; partial response in 14). Among 12 patients (67%) who underwent conversion surgery, R0 resection was conducted in eight, and no residual tumour was observed in two. For the population overall, the median overall survival was 24 months (95% confidence intervaI=21 months-not reached) and the 1-year overall survival rate was 95% (95% confidence intervaI=67-98%). Grade 3/4 neutropenia and grade 2 peripheral sensory neuropathy occurred in five (22%) and six (26%) patients, respectively, while no patient developed grade 3/4 thrombocytopenia.

CONCLUSION

Chemotherapy with itraconazole is promising for patients with unresectable gastric cancer.

Prospective Multicenter Study on the Prognostic and Predictive Impact of Tumor Budding in Stage II Colon Cancer: Results From the SACURA Trial

PURPOSE

The International Union Against Cancer highlighted tumor budding as a tumor-related prognostic factor. International assessment criteria for tumor budding were recently defined by the 2016 International Tumor Budding Consensus Conference (ITBCC2016). This study aimed to clarify the prognostic and predictive values of tumor budding in a randomized controlled trial evaluating the superiority of adjuvant chemotherapy with oral tegafur-uracil over surgery alone for stage II colon cancer (SACURA trial; ClinicalTrials.gov identifier: NCT00392899).

PATIENTS AND METHODS

Between 2006 and 2010, we enrolled 991 patients from 123 institutions with stage II colon cancer. Tumor budding was diagnosed by central review on the basis of the criteria adopted in the ITBCC2016. We prospectively recorded all clinical and pathologic data, including the budding grade, and performed prognostic analyses after 5 years of completing the patients’ registration.

RESULTS

Of 991 tumors, 376, 331, and 284 were classified as BD1, BD2, and BD3, respectively; the 5-year relapse-free survival (RFS) rate was 90.9%, 85.1%, and 74.4%, respectively (P < .001), and ranged widely in T4 tumors (86.6% to 53.3%). The budding grade significantly correlated with recurrence in the liver, lungs, lymph nodes, and peritoneum (P < .001 to .01). Multivariable analysis revealed that budding and T stage exerted an independent impact on RFS, and on the basis of the Harrell concordance index, these two factors substantially contributed to the improvement of the Cox model for predicting RFS. Both the BD2 and BD3 groups demonstrated greater improvement in the 5-year recurrence rate in the adjuvant chemotherapy group than the surgery-alone group by approximately 5%, but the difference was statistically nonsignificant.

CONCLUSION

Tumor budding grade on the basis of the ITBCC2016 criteria should be routinely evaluated in pathologic practice and could improve the benefit of adjuvant chemotherapy for stage II colon cancer.

A phase II study of S-1, oxaliplatin, and nab-paclitaxel, and itraconazole aimed at conversion surgery for advanced and recurrent gastric cancer

4026

Background: Preclinical and clinical studies demonstrated that itraconazole, a common anti-fungal agent, has anticancer activity. The purpose of this study was to evaluate the efficacy of the chemotherapy with itraconazole on unresectable, metastatic, and recurrent gastric cancer. Methods: All patients were referred to our clinic with a clinical diagnosis of unresectable gastric cancer. The regimen consisted of 160 mg/m2 nab-paclitaxel IV on day 1, 100 mg/m2 oxaliplatin IV on day 1, 60 mg/m2 S-1 orally on days 1-7, and 400mg itraconazole orally on days -1 to 3, repeated every 3 weeks. Conversion surgery was allowed. The primary endpoint was overall survival (OS). Results: Between 2015 and 2018. 23 patients were enrolled. Their median age was 68 years (range 40-80 years); stomach/gastroesophageal junction: 21/2; Stage IIIA/IIIB/IV: 2/1/20. Among 10 patients who had liver metastases, 2 had simultaneous lung metastases. Nine patients had peritoneal dissemination. Five patients with stage IV had recurrent disease after primary surgery followed by adjuvant S-1. The other 18 patients had no history of surgery or chemotherapy. Response rate was 70% (CR/PR: 2/14). Among 12 patients (67%) who had conversion surgery, R0 resection was conducted in 8 and no residual tumor was observed in 2. Among enrolled 23 patients, median OS was 22 months (95%CI: > 12 months) and 1-year OS rate was 81.8% (95%CI: 46.7%―95.5%). Grade 3/4 neutropenia in 5 (22%), no grade 3/4 thorombocytopenia, grade 2 peripheral sensory neuropathy in 6 (26%). Conclusions: The addition of itraconazole to chemotherapy showed promising efficacy with high conversion surgery rate and with acceptable toxicities. Clinical trial information: UMIN000021340.

[Radiofrequency Ablation for Colorectal Liver Metastases]

AIM

The significance of radiofrequency ablation(RFA)for colorectal liver metastases(CRLM)remains to be elucidated. Therefore, this retrospective study aimed to evaluate the therapeutic efficacy of RFA for local recurrence of CRLM.

SUBJECTS

Between June 2005 and June 2017, we retrospectively examined 63 patients(137 nodules)with CRLM who underwent RFA.

RESULTS

The local recurrence rate was 36.5%, and the median local recurrence free survival(LRFS)was 26.3 months. We compared treatment background between the 2 groups with(50 nodules)and without(87 nodules)local recurrence. In the multivariate analysis, tumor size of the ablated lesion and method for ablation(direct tumor puncture)were independent risk factors for local recurrence. Receiver operating characteristic curve for tumor size of the ablated lesion showed an optimal cutoff value for tumor size of 1.8 cm(AUC=0.734, 95%CI: 0.612-0.855, p<0.0001).

CONCLUSIONS

RFA for effective control of local recurrence of CRLM might be suitable for selected patients with tumor size of ablated lesion ofC1.8 cm and no touch ablation method.

[A Resected Case of Hilar Cholangiocarcinoma Confirmed as Pathological Complete Response Following Neoadjuvant S-1 Monotherapy]

A 74-year-old man was admitted to a local hospital with liver dysfunction. Imaging modalities revealed bile duct stenosis at the bifurcation of the anterior and posterior trunk. Exfoliative cytology of the bile and brushing cytology of the bile duct both revealed Class Ⅴ, and biopsy from the stenotic bile duct showed well differentiated adenocarcinoma. We diagnosed the patient with hilar cholangiocarcinoma and performed extended right bisectionectomy and biliary reconstruction after percuta- neous transhepatic right portal vein embolization(PTPE). Preoperatively, he was administered S-1(80mg/body weight/day) orally for 19 days. Histopathological assessment of the resected specimen revealed hemosiderin-laden macrophages without viable cancer cells, confirmingpatholog ical complete response(pCR).

Updated 5-year survival and exploratory T x N subset analyses of ACTS-CC trial: a randomised controlled trial of S-1 versus tegafur-uracil/leucovorin as adjuvant chemotherapy for stage III colon cancer

Objective

Adjuvant Chemotherapy Trial of TS-1 for Colon Cancer (ACTS-CC), a randomised phase III trial, demonstrated that adjuvant therapy with S-1 for stage III colon cancer was non-inferior in 3-year disease-free survival (DFS) to that of tegafur-uracil plus leucovorin (UFT/LV). We updated DFS and overall survival (OS) and performed T x N subset analysis.

Methods

A total of 1518 patients with curatively resected stage III colon cancer were randomly assigned to receive S-1 (80-120  mg/day on days 1-28 every 42 days, four courses) or UFT/LV (UFT: 300-600  mg/day and LV: 75  mg/day on days 1-28 every 35 days, five courses).

Results

The 5-year DFS rates of the S-1 and UFT/LV group were 70.2 % and 66.9 %, respectively (HR 0.88; 95%  CI 0.74 to 1.06; p=0.177), and non-inferiority of DFS was reconfirmed with a median of 63.5-month follow-up. The similarity of OS was also confirmed (HR 0.92; 95%  CI 0.72 to 1.17; p=0.488); 5-year OS rates of the S-1 and UFT/LV group were 86.0 % and 84.4 %, respectively. No significant interactions were identified between the major baseline characteristics and DFS of the S-1 and UFT/LV groups, except for histological type; S-1 was more favourable in patients with poorly differentiated adenocarcinoma. Patient outcomes were well separated by TNM-substages (IIIA/IIIB/IIIC). With the patients divided into 20 subsets by T and N factors, the DFS and OS rates of T3 and N1 subset, which accounted for 62 % of stage IIIB patients and 44 % of all studied subjects, were significantly better than those of the other subsets in stage IIIB and similar to those of stage IIIA.

Conclusions

Adjuvant therapy of S-1 for stage III colon cancer was reconfirmed to be non-inferior in DFS to those of UFT/LV after long follow-up. No difference in OS was also demonstrated. T3N1 patients might be considered separately from other patients included in stage IIIB because of its favourable outcome.

Trial registration number

NCT00660894.

Primary closure of a spontaneous esophageal rupture under hand-assisted laparoscopy: a case report

Spontaneous rupture of the esophagus, which is also known as Boerhaave’s syndrome, is a rare life-threatening condition that requires urgent surgical management. The optimal treatment involves surgical repair of the esophageal defect, which is usually accomplished via laparotomy, thoracotomy, or both, and mediastinal debridement. Here, we report a case of spontaneous rupture of the esophagus that was treated with suturing repair and drain insertion using a hand-assisted laparoscopic approach.

Observational cohort study focused on treatment continuity of patients administered XELOX plus bevacizumab for previously untreated metastatic colorectal cancer

Background

There has been remarkable progress in systemic chemotherapy for metastatic colorectal cancer due to the widespread use of irinotecan, oxaliplatin, anti-vascular endothelial growth factor antibody, and anti-epidermal growth factor receptor antibody. It is important to continue treatment with the optimal combination of these drugs and prolong progression-free survival (PFS) to improve overall survival (OS). We conducted a prospective observational cohort study of 40 patients treated with XELOX plus bevacizumab for previously untreated metastatic colorectal cancer to investigate treatment continuity.

Patients and methods

Eligibility criteria were as follows: 1) histologically confirmed metastatic colorectal cancer; 2) lesions evaluable by imaging; 3) previously untreated; 4) suitable condition to receive XELOX plus bevacizumab; and 5) written informed consent. Outcomes were treatment continuity, overall response rate, resection rate, liver resection rate, time to treatment failure, PFS, and OS. Forty patients were enrolled and followed up for 2 years.

Results

Between July 2010 and June 2012, 40 patients were enrolled. The median number of treatment cycles was 7.5, and the reasons for discontinuation of treatment were as follows: complete response (five patients), resection (ten patients), progression (15 patients), adverse events (seven patients), and patient refusal (three patients). The overall response rate was 57.5%, resection rate was 25%, and liver resection rate was 15%. After a median follow-up of 31.4 months, the median time to treatment failure, PFS, and OS were 5.3, 13.3, and 38.9 months, respectively.

Conclusion

Although the median time to treatment failure was 5.3 months, the median PFS and OS were prolonged to 13.3 and 38.9 months, respectively. This may have resulted from the chemotherapy-free interval due to complete response in five patients and resection in ten patients.

Clinical efficacy of dual-phase scanning using (68)Ga-DOTATOC-PET/CT in the detection of neuroendocrine tumours

AIM

To investigate whether delayed scanning at approximately 90 minutes post-injection of (68)Ga-labelled 1,4,7,10-tetraazacyclododecane-N,N',N″,N‴-tetraacetic acid-d-Phe(1)-Tyr(3)-octreotide (DOTATOC) had any clinical benefits regarding the evaluation of neuroendocrine tumours (NETs), relative to conventional combined positron-emission tomography (PET) and computed tomography (CT) at 60 minutes post-injection.

MATERIALS AND METHODS

Fifty-four patients who underwent DOTATOC-PET/CT for suspected or known NETs were retrospectively reviewed. PET/CT was performed twice at approximately 60 and 90 minutes post-injection. For visual analysis, a five-point grading scale (0: definitely normal to 4: definitely abnormal) was used, and grade 3-4 lesions were regarded as positive. For quantitative analysis, the time course of the maximum standardised uptake value (SUVmax) in each lesion and the mean SUV of physiological uptake in the liver were evaluated.

RESULTS

Of the 54 patients, 43 had a total of 132 lesions. In interpreting the early images, there were four grade 3 lesions, and the remaining 128 lesions were grade 4. All 132 lesions were grade 4 in the delayed images. SUVs and tumour-to-liver ratios for hepatic lesions were slightly higher in delayed scanning than in early scanning (SUV, 26.8±21.2 versus 28.2±21.2 [p<0.01]; tumour-to-liver ratio, 5.9±4.5 versus 6.2±4.6 [p<0.01]), which did not affect the detection rate. Additionally, bone and peritoneal metastases had slightly higher SUVs at delayed imaging (p<0.05), but there was no difference in diagnostic performance. No significant difference in the SUVs for pancreatic lesions and primary sites in the bowel were observed between the early and delayed scans.

CONCLUSION

Delayed scanning may be helpful for improving diagnostic confidence in some cases, although it provided no specific merits for diagnostic accuracy in detecting primary or metastatic NETs.

Safety management of nuclear medicine personnel with visualisation of air dose rate

Many people are anxious about radiation exposure for the reason that radiation cannot be seen. With the aim of devising a way for medical personnel to perform their medical duties without worry about radiation exposure, we attempted safety management using a system that displays the air dose of radiation in real time. Measurements were made in a lung ventilation scintigraphy examination room with the use of Xe-133. An SCI-type RI detector from Hamamatsu Photonics, which displays the air dose rate in real time, was used for the measurements. These radiation measurements were continued from the start to finish of the examination. The measurements were made in two locations, on the patient inhalation tube side and on the opposite side. Measurements were made on the patient tube side in 24 tests and on the opposite side in 12 tests. The maximum air dose rate was 3.7 ± 2.1 μSv/h on the patient tube side and 1.1 ± 0.5 μSv/h on the opposite side. Thus, the level on the opposite side was about 1/5 that of the tube side. To accurately perform lung ventilation scintigraphy, a medical worker needs to observe the patient's breathing status up close. Because of this, some medical workers are worried about radiation exposure during tests. The simplest way to reduce exposure would be to maintain a distance from the examination tube that is the source of radiation. The measurements in this study were made to encourage medical workers' recognition of this fact. Displaying specific numbers not only serves as basic data for managing staff operations, but is also thought to reassure workers through visualization.

S-1 as adjuvant chemotherapy for stage III colon cancer: a randomized phase III study (ACTS-CC trial)

BACKGROUND

S-1 is an oral fluoropyrimidine whose antitumor effects have been demonstrated in treating various gastrointestinal cancers, including metastatic colon cancer, when administered as monotherapy or in combination chemotherapy. We conducted a randomized phase III study investigating the efficacy of S-1 as adjuvant chemotherapy for colon cancer by evaluating its noninferiority to tegafur-uracil plus leucovorin (UFT/LV).

PATIENTS AND METHODS

Patients aged 20-80 years with curatively resected stage III colon cancer were randomly assigned to receive S-1 (80-120 mg/day on days 1-28 every 42 days; four courses) or UFT/LV (UFT: 300-600 mg/day and LV: 75 mg/day on days 1-28 every 35 days; five courses). The primary end point was disease-free survival (DFS) at 3 years.

RESULTS

A total of 1518 patients (758 and 760 in the S-1 and UFT/LV group, respectively) were included in the full analysis set. The 3-year DFS rate was 75.5% and 72.5% in the S-1 and UFT/LV group, respectively. The stratified hazard ratio for DFS in the S-1 group compared with the UFT/LV group was 0.85 (95% confidence interval: 0.70-1.03), demonstrating the noninferiority of S-1 (noninferiority stratified log-rank test, P < 0.001). In the subgroup analysis, no significant interactions were identified between the major baseline characteristics and the treatment groups.

CONCLUSION

Adjuvant chemotherapy using S-1 for stage III colon cancer was confirmed to be noninferior in DFS compared with UFT/LV. S-1 could be a new treatment option as adjuvant chemotherapy for colon cancer.

CLINICALTRIALSGOV

NCT00660894.

A patient with recurrent breast cancer showing long-term survival after developing pericardial effusion and cardiac tamponade caused by carcinomatous pericarditis

BACKGROUND

Malignant pericardial effusion caused by carcinomatous pericarditis is a complication of advanced malignancy. Breast cancer is the second most important cause of malignant pericardial effusion. Malignant pericardial effusion is the end stage of breast cancer, and the prognosis is very poor. Pericardial effusion may cause cardiac tamponade and sudden death if it is not controlled properly. There is a debate on which is the best method to control pericardial effusion.

CASE REPORT

We describe the clinical course of a 55-year-old woman with recurrent breast cancer, pericardial effusion, and cardiac tamponade caused by carcinomatous pericarditis. Thoracoscopic pericardial window was performed to control the pericardial effusion. The patient survived for about 5 years after being diagnosed with pericardial metastases.

CONCLUSION

The observed long-term survival in such a patient with the development of pericardial effusions and cardiac tamponade caused by carcinomatous pericarditis attributable to breast cancer is rare. Thoracoscopic pericardial window was effective in controlling the pericardial effusion.

Observational cohort study focused on treatment continuity of patients (pts) treated with XELOX plus bevacizumab (BV) for previously untreated metastatic colorectal cancer (mCRC)

661

Background: Systemic chemotherapy for unresectable mCRC has remarkably progressed as a results of wide spread use of irinotecan, oxaliplatin, anti-VEGF antibody and anti-EGFR antibody. It is important to continue treatment combined with these drugs and prolong progression-free survival so as to improve overall survival. Methods: We planned and conducted the prospective observational cohort study of 40 pts treated with XELOX + BV for previously untreated mCRC to investigate the treatment continuity of XELOX + BV. Endpoints were time to treatment-failure (TTF), overall response rate, resection rate, liver resection rate, progression-free survival (PFS), overall survival (OS) and safety. Eligibility criteria were (1) histologically confirmed mCRC, (2) with lesions evaluable by imaging, (3) previously untreated (except for surgery), (4) with condition enough to receive XELOX + BV, (5) written informed consent. Forty pts were planned to be enrolled during 2 years and followed up to 2 years. Results: Between July 2010 and June 2012, 40 pts were enrolled. Baseline characteristics were the following; male/female 24/16, median age 63 yrs (range 35-84 yrs), ECOG PS 0/1/2 33/6/1, primary cite colon/rectum 24/16, primary resection prior XELOX+BV yes/no 35/5, metastatic cite liver/lung/paraaorta/peritoneal/local recurrence/others 23/16/4/7/3/4, the number of metastatic cite 1/2/3 26/9/5.The median TTF was 5.3 months (95%CI: 3.6 – 9.1 months), and the reasons for treatment discontinuation were the following; CR 4 pts, resection 10 pts, progression 12 pts, adverse events 7 pts and pts refusal 3 pts. Four pts continued their treatments.The overall response rate was 52.5% (CR 6 pts and PR 15 pts), resection rate was 25.0% (liver 6 pts, lung 2 pts and primary 2 pts), and liver resection rate was 15.0%. The median PFS was 13.3 months (95%CI: 9.8 months – NR) and the median OS was not reached. Conclusions: Although the median TTF was 5.3 months, the median PFS was prolonged to 13.6 months. This might result from chemo-free interval caused by 4 pts’ CR and 9 pts’ resections. We will further investigate 40 pts’ 2-year survival data. Clinical trial information: UMIN000003416.

Absorption and bioavailability of diclofenac after rectal administration of diclofenac-na gel preparation in rat and man

In order to evaluate diclofenac-Na (DC-Na) micro-enema, DC-Na gel preparations were administered to rats and man. When DC-Na gel preparations were rectally administered at various pH (pH 5- 8) to rats, their bioavailability increased at higher pH. The bioavailability of DC-Na gel preparations (pH 8.0) in rats was significantly higher than that with conventional suppository bases, Witepsol H-15 and polyethylene glycol 1000 (PEG 1000). In man, the DC-Na gel preparation showed higher Cmax and higher bioavailability than commercial suppository made with an oily base. DC-Na gel preparations containing 10% v/v oleic acid showed a prolonged action. The irritative effect of DC-Na gel preparation on rectal mucosa in rats was weaker than that of PEG 1000, but similar to that of Witepsol H-15. Therefore, the present results suggest that gel preparation is a favorable form for rectal administration of diclofenac-Na.

Noninferiority of S-1 to UFT/LV as adjuvant chemotherapy for stage III colon cancer: A randomized phase III trial (ACTS-CC)

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Background: The ACTS-CC trial is a phase III trial designed to validate non-inferiority of S-1 to UFT/LV, a standard treatment in Japan as adjuvant chemotherapy for stage III colon cancer. This is the first report which evaluated the efficacy of S-1 as adjuvant therapy for colon cancer. Methods: 20-80 aged patients with stage III colon cancer who underwent curative surgery were randomly assigned to receive S-1 (80, 100, or 120 mg/day according to BSA on days 1 to 28, followed by 14 days rest, 4 courses) or UFT/LV (UFT: 300 to 600 mg/day according to BSA and, LV: 75 mg/day on days 1 to 28, followed by 7 days rest, 5 courses). Primary endpoint was DFS. Sample size was 1,480 determined with one-sided alpha of 0.05, power of 0.80, and non-inferiority margin of hazard ratio (HR) of 1.29. Results: Among 1535 enrolled patients between Apr. 2009 and Jun. 2010, 1518 patients (758 in S-1 group, 760 in UFT/LV group) were included in the efficacy analysis. Median follow-up was 41.3 months, the mean age at enrollment was 64.5 years, wide lymph node dissection (D3) was done in 79.8%, the median number of dissected lymph nodes was 17, and stage IIIA/IIIB/IIIC were 15%/71%/14%. The 3-year DFS rate was 75.5% in S-1 group and 72.5% in UFT/LV group. The HR of DFS was 0.85 (95%CI: 0.70-1.03) and non-inferiority of S-1 was demonstrated (p<0.0001). The completion rate of the protocol treatment was 76.5% in S-1 group and 72.5% in UFT/LV group. The overall incidence of grade ≥3 adverse events (AEs) in S-1 group and UFT/LV group were 16.0% and 14.4%: 4.4% and 5.5% for diarrhea, 4.9% and 3.5% for anorexia, 0.7% and 0.4% for leucopenia, 0.9% and 0.1% for anemia, 0.1% and 0.4% for thrombocytopenia, 1.2% and 1.5% for hyperbilirubinemia, 0.8% and 2.1% for AST elevation, and 1.1% and 3.3% for ALT elevation, respectively. Conclusions: Adjuvant therapy of S-1 for stage III colon cancer was demonstrated to be non-inferior in DFS to that of UFT/LV. Although AE profiles differed between S-1 group and UFT/LV group in this trial, incidence and degree of AEs were acceptable, and the completion rate of the protocol treatment was high. Adjuvant chemotherapy using S-1 will be a treatment option for stage III colon cancer. Clinical trial information: NCT00660894.

Safety of UFT/LV and S-1 as adjuvant therapy for stage III colon cancer in phase III trial: ACTS-CC trial

BACKGROUND

The Adjuvant Chemotherapy Trial of TS-1 for Colon Cancer (ACTS-CC) is a phase III trial designed to validate the non-inferiority of S-1 to UFT/leucovorin (LV) as postoperative adjuvant chemotherapy for stage III colon cancer. We report the results of a planned safety analysis.

METHODS

Patients aged 20-80 years with curatively resected stage III colon cancer were randomly assigned to receive UFT/LV (UFT, 300 mg m(-2) per day as tegafur; LV, 75 mg per day on days 1-28, every 35 days, 5 courses) or S-1 (80, 100, or 120 mg per day on days 1-28, every 42 days, 4 courses). Treatment status and safety were evaluated.

RESULTS

Of 1535 enrolled patients, a total of 1504 (756 allocated to S-1 and 748 to UFT/LV) were analysed. The completion rate of protocol treatment was 77% in the S-1 group and 73% in the UFT/LV group. The overall incidence of adverse events (AEs) were 80% in S-1 and 74% in UFT/LV. Stomatitis, anorexia, hyperpigmentation, and haematological toxicities were common in S-1, whereas increased alanine aminotransferase and aspartate aminotransferase were common in UFT/LV. The incidences of grade 3 AEs were 16% and 14%, respectively.

CONCLUSION

Although AE profiles differed between the groups, feasibility of the protocol treatment was good. Both S-1 and UFT/LV could be safely used as adjuvant chemotherapy.

Utility of FDG PET/CT in IgG4-related systemic disease

IgG4-related systemic disease (IgG4-RSD) is an emerging clinical entity about which much remains to be elucidated, in terms of its aetiology, pathogenesis, diagnosis, treatment and outcome. Autoimmune pancreatitis (AIP) and Mikulicz disease (MD) are the two major, well-studied constituents of IgG4-RSD. AIP and MD have common characteristics of forming tumour-mimicking lesions that consist of lymphoplasmacytic infiltrates and fibrosclerosis with numerous immunoglobulin G4 (IgG4)-positive plasma cells, as well as various multi-organ manifestations of IgG4-RSD. 2-[(18)F]-fluoro-2-deoxy-d-glucose positron-emission tomography/ computed tomography (FDG PET/CT) enables the acquisition of whole-body images and provides functional information about disease activity; as such it has a valuable role in staging extent of disease, guiding biopsy, and monitoring response to treatment. However, FDG PET/CT is likely to be only one component of the management strategy, and clinical, laboratory, imaging and histological findings are crucial in the overall diagnosis of the condition. At present FDG PET/CT does not have a well-established role in the assessment of patients with IgG4-RSD and future prospective studies are required to define the cost-effectiveness and clinical impact in this patient group more accurately.

Note: high-pressure generation using nano-polycrystalline diamonds as anvil materials

Nano-polycrystalline diamonds (NPDs) consist of nanosized diamond grains oriented in random directions. They have high toughness and isotropic mechanical properties. A NPD has neither the cleavage feature nor the anisotropy of hardness peculiar to single-crystal diamonds. Therefore, it is thought to be useful as a diamond anvil. We previously reported the usefulness of a NPD as an anvil for high-pressure development. In this study, some additional high-pressure generating tests using diamond anvils of various shapes prepared from NPDs were conducted to investigate the advantage of using NPDs for anvil applications. The results revealed that the achievable pressure value of a NPD anvil with a culet size of more than 300 μm is about 1.5 to 2 times higher than that of single-crystal diamond anvils, indicating that NPD anvils have considerable potential for large-volume diamond anvils with large culet sizes.

[A successful case treated with S-1 and zoledronic acid for multiple bone metastasis of breast cancer]

The patient was a 55-year-old woman undergoing surgery for T2, N1, M0, stage II B breast cancer in November 1997. UFT and tamoxifen were administered as adjuvant chemotherapy. S-1 and zoledronic acid were then administered for the recurrence of multiple bone metastasis detected in January 2008. A significant improvement was achieved, and a long-term positive effect was confirmed until an exacerbation of bone metastasis in February 2010. S-1 and zoledronic acid therapy have few adverse drug reactions, they promptly manifest their effect, and are favored as a first choice for treating bone metastasis of breast cancer.