Peritoneal Carcinomatosis in Gastro-Entero-Pancreatic Neuroendocrine Neoplasms: Clinical Impact and Effectiveness of the Available Therapeutic Options

BACKGROUND

Peritoneal carcinomatosis (PC) can affect the quality of life of patients with gastro-entero-pancreatic neuroendocrine neoplasms (GEP-NENs). Peritoneal disease control by medical therapies in these patients has been poorly investigated Objectives: To describe, in a consecutive series of GEP-NENs, the clinical impact of PC and to report the effectiveness of available treatments in PC control.

METHODS

A retrospective, monocenter analysis was performed of 135 GEP-NENs (1993-2016) with at least a 12-month follow-up. Peritoneal disease progression was defined as detection of a significant increase in size or appearance of new implants by imaging.

RESULTS

A total of 62.9% of cases had diffuse PC (involving at least 2 abdominal quadrants). According to WHO 2017 classification, cases were 42.3% neuroendocrine tumors NET-G1, 45.5% NET-G2, 6.5% NET-G3, 4.9% neuroendocrine carcinomas NEC-G3, and 0.8% mixed neuroendocrine-nonneuroendocrine neoplasms. Bowel obstruction occurred in 30 (22.2%) patients mainly depending on size of peritoneal implants (HR: 1.10; 95% CI: 1.02-1.20; p = 0.01). Patients with diffuse PC treated with peptide receptor radionuclide therapy (PRRT) showed peritoneal progression in 37.5% of cases, and bowel obstruction or ascites in 28.1%. Better peritoneal disease control was observed in cases receiving somatostatin analogs at first-line therapy, probably due to a less aggressive disease behavior for these patients.

CONCLUSIONS

Bowel obstruction is not uncommon in GEP-NENs with PC. PRRT should be adopted with caution in GEP-NENs with diffuse PC, but larger series are needed to confirm these data.

Application and Dosimetric Requirements for Gallium-68-labeled Somatostatin Analogues in Targeted Radionuclide Therapy for Gastroenteropancreatic Neuroendocrine Tumors

Neuroendocrine tumors (NETs) are associated with variable prognosis, with grade 1 and 2 NETs having more favorable outcomes than grade 3. Patients with gastroenteropancreatic (GEP)-NET need individualized interdisciplinary evaluations and treatment. New treatment options have become available with significant improvements in progression-free survival. Peptide receptor radionuclide therapy (PRRT) using (90)Y or (177)Lu-labeled somatostatin analogues (SSTa) has also shown promise in the treatment of advanced progressive NETs. (68)Ga-1,4,7,10-tetraazacyclodecane-1,4,7,10-tetraacetic acid (DOTA)-SSTa can be used as companion imaging agents to assist in radionuclide therapy selection. (68)Ga-DOTA-SSTa PET/computed tomography might also provide information for prognosis, tumor response assessment to PRRT, and internal dosimetry.

Once-weekly stereotactic radiotherapy for patients with oligometastases: compliance and preliminary efficacy

AIMS AND BACKGROUND

This retrospective analysis reports the outcomes obtained with an original once-weekly stereotactic radiotherapy fractionation given to patients affected by evolving oligometastases from different solid malignancies.

METHODS

From 2009 to 2011, patients with symptomatic and/or evolving oligometastases were submitted to a median 5-fraction cycle of stereotactic radiotherapy of one fraction per week in order to exploit a radiobiological rationale designed to increase the therapeutic index. Individual fractionation was mainly planned according to patient performance status, oligometastasis size and site, and record of previous irradiation in the same site.

RESULTS

Thirty-six patients in stage IV UICC-TNM affected by oligometastases were treated with image-guided intensity-modulated stereotactic tomotherapy with a single weekly radiation. Median age was 70 years (range, 34-89). The median weekly single dose, number of fractions and overall total radiation dose were 7 Gy, 5 fractions and 35 Gy, respectively. Thirty-five (97%) patients completed the treatment schedule. No patient suffered mild or severe radiation-related side effects. Twenty-one (87%) of 24 patients with local pain had complete symptomatic response within 30 days following the end of radiotherapy. Local control assessed at imaging after stereotactic radiotherapy was evidenced in 30 (83%) patients. Median time to response after the end of radiotherapy was 40 days.

CONCLUSIONS

The original radiotherapy regimen delivering only a single stereotactic dose per week seems to be highly feasible with an interesting high efficacy rate in patients with oligometastases from different solid tumors. Overall, the once-weekly treatment was very compliant in an advanced cancer stage especially for elderly and frail patients.

Somatostatin-receptor-based imaging and therapy of gastroenteropancreatic neuroendocrine tumors

Somatostatin receptor imaging (SRI) with [(111)In-DTPA(0)]octreotide has proven its role in the diagnosis and staging of gastroenteropancreatic neuroendocrine tumors (GEPNETs). Newer radiolabeled somatostatin analogs which can be used in positron emission tomography (PET) imaging, and which have a higher affinity for the somatostatin receptor, especially receptor subtype-2, have been developed. It would be desirable, however, if one radiolabeled analog became the new standard for PET imaging, because the current application of a multitude of analogs implies a fragmented knowledge on the interpretation of the images that are obtained in clinical practice. In our view, the most likely candidates for such a universal PET tracer for SRI are [(68)Ga-DOTA(0),Tyr(3)]octreotate or [(68)Ga-DOTA(0),Tyr(3)]octreotide. Treatment with radiolabeled somatostatin analogs is a promising new tool in the management of patients with inoperable or metastasized neuroendocrine tumors. Symptomatic improvement may occur with all (111)In-, (90)Y-, or (177)Lu-labeled somatostatin analogs that have been used for peptide receptor radionuclide therapy (PRRT). The results that were obtained with [(90)Y-DOTA(0),Tyr(3)]octreotide and [(177)Lu-DOTA(0),Tyr(3)]octreotate are very encouraging in terms of tumor regression. Also, if kidney protective agents are used, the side effects of this therapy are few and mild, and the median duration of the therapy response for these radiopharmaceuticals is 30 and 40 months respectively. The patients' self-assessed quality of life increases significantly after treatment with [(177)Lu-DOTA(0),Tyr(3)]octreotate. Lastly, compared to historical controls, there is a benefit in overall survival of several years from the time of diagnosis in patients treated with [(177)Lu-DOTA(0),Tyr(3)]octreotate. These data compare favorably with the limited number of alternative treatment approaches. If more widespread use of PRRT can be guaranteed, such therapy may well become the therapy of first choice in patients with metastasized or inoperable GEPNETs.

Systemic therapy for neuroendocrine tumours of gastroenteropancreatic origin

Systemic therapy is one of a number of treatment options routinely used in the management of advanced, unresectable neuroendocrine tumours (NETs). In contrast to many of the other NET treatment modalities, there is at least some evidence base to justify its use. Even so, well-designed clinical trials are limited, since conducting clinical research in this complex group of rare cancers is challenging. The remit of this review article is to summarise the oncology literature and explain the role of systemic therapy in treating NETs of gastroenteropancreatic origin, identifying benefits and limitations. The molecular biology of NETs is now being unravelled, which affords new opportunities for development of mechanism-driven therapies. The rationale for some of the newer systemic targeted therapies that are showing promise in the clinic is discussed.

Intraoperative radiation therapy in the multimodality approach to upper aerodigestive tract cancer

The cure rate of operable lung cancer and locally advanced head and neck cancer remains suboptimal, with a limited rate of local control despite improvements in the surgical removal of primary tumors and in methods for mediastinal lymph node dissection, in particular. The efficacy of adjuvant therapy, such as EBRT, has improved, and the immediate efficacy of new chemotherapeutic drugs is increasingly significant, although local recurrences remain frequent. Locoregional failure is not uncommon in upper aerodigestive tract cancers. Factors limiting radiocurability for locally advanced (stage III) lung cancer include mediastinal intolerance of irradiation (high risk of mediastinal fibrosis, which increases exponentially when levels of much more than 50 Gy are administered to the whole mediastinum) and the very high radiosensitivity of the healthy lung, which can develop fibrosis with relatively small or moderate doses starting at 18 to 20 Gy, and even more frequently when larger volumes are irradiated. Head and neck neoplasms are less difficult sites in which to administer doses of up to 70 Gy of external beam radiotherapy initially, but, like locoregionally recurrent lung cancers, they are not easily reirradiated with tumoricidal doses of EBRT. For these reasons, IORT seems to be a good option for increasing local control, because areas of [figure: see text] residual microscopic disease may be irradiated using IOERT approaches without affecting critical organs to the same extent. In addition, careful patient selection is paramount. Combined modality treatment regimens incorporating IORT may benefit patients with locally advanced disease. The ability of IORT to sterilize microscopic residual disease can enhance the "completeness" of resection and thus, theoretically, improve local control. Although distant disease dissemination remains by far the overriding issue, as newer effective agents emerge, local failure will continue to be a problem. Preliminary studies have demonstrated that IORT can be administered to patients who have locally advanced NSCLC and head and neck cancer, in the context of aggressive combined modality therapy, and is generally well tolerated. Long-term efficacy and benefit can only be determined in the setting of carefully designed clinical trials. (See the article by Thomas and Merrick elsewhere in this issue for further discussion of this topic.) Several relatively small, single-institution pilot studies exploring the utility and benefit of IORT for locally advanced upper aerodigestive tract cancers have been conducted. Clear conclusions have been difficult to determine because of the mixing of disease stages, varying degrees and completeness of surgical resection, varying radiation doses, different schemas, and other factors. Yet, given the major morbidity and mortality associated with locally recurrent lung cancer, methods of improving local control need to be pursued and refined. Encouraging preliminary data suggest that IOERT can be safely administered and may benefit local control. Based on several centers' expertise in the combined modality treatment of locally advanced lung cancer and familiarity with IORT, the UCSF Thoracic Oncology Program has proposed a multicenter phase 2 study incorporating IORT in a combined multimodality treatment schema for patients who have completely resected locally advanced stage IIIA and IIIB NSCLC (nonpleural effusion, non-N3) (Fig. 1). It is hoped that this study will commence in the upcoming year.

Modulation of dose intensity in aerodigestive tract cancers: strategies to reduce toxicity

Advances in diagnostic and therapeutic radiology and a better understanding of cell biology are being applied in practical ways to modulate treatment morbidity. Conformal radiotherapy targets the cancer precisely and can be combined with new systemically administered radiosensitizers. The successes of conventional chemoradiation programs support continued study of newer ways to deliver systemic radiosensitizing chemotherapy. However, chemoradiation creates a narrower therapeutic window compared to irradiation alone and increased treatment intensity, even with conformal chemoradiation techniques, can potentially result in frequent complications, detrimental treatment delays, and decreased quality of life. Treatment schedules employing a "best tolerated time" modelfor systemic administration of radiosensitizing chemotherapy, based on the concept of chronotolerance, offer attractive ways to address the challenging problem of normal tissue toxicity associated with conformal chemoradiation. This approach may be beneficial in the elderly and those medically unfit to tolerate traditional dose-intense combined-modality schedules. Further evaluation of this concept is warranted, based on existing data.

[Medical treatment of digestive neuroendocrine tumours]

Surgery is the only therapy able to cure patients with digestive neuroendocrine tumor. However, due to the presence of diffuse metastases, radical surgery is often not feasible. In these cases, medical treatment plays a critical role, because of its ability to control symptoms in functioning tumors and to inhibit tumor growth. Different therapeutic approaches, such as chemotherapy, hepatic artery chemoembolization and targeted radio-nuclide therapy can be used alone or combined to the biologic treatment with somatostatin analogues and interferon. However, an accurate staging by imaging procedures plus a histological, immunohistochemical and biomolecular examination must be performed before planning an optimal medical treatment.

Recent advances in the nonsurgical treatment of upper gastrointestinal tract tumors

Cancers of the esophagus, stomach and pancreas constitute a major cause of cancer death worldwide. Despite improvements in both surgical techniques and chemotherapy regimens these tumors remain a great therapeutic challenge and most patients still die of their disease, even after apparent 'curative resection'. There is a clear need for more effective treatments, particularly for patients with advanced disease, since this is the most common presenting stage. In this review we will discuss the clinical strategies in use and identify the best current treatment options based on randomized clinical trial data. Novel strategies under investigation are discussed and speculation made as to which will be standard treatments of the future.

[Intra-operative radiation therapy in tumors of the digestive tract]

All the retrospective and prospective studies concerning IORT in tumors of the digestive tract tend to substantiate a significant improvement in local control without a significant increase in survival. Improvements in the results of IORT can be expected in the near future, and may occur on several fronts: - Technological improvements: advances in the development of IORT machines, with the construction of electron accelerators specifically designed for IORT; greater precision in the systems of collimation (asymmetric collimator, multiple leaves, computerization of the control of collimation); and increased adaptability of the localizers to each clinical situation and to each patients. - Increase in the biological effects of IORT: determination of the exact role of IORT in relation to other therapeutic methods, its integration into the global therapeutic strategy for cancer, and the optimization of IORT doses should all be studied in phase II and III trials. Interesting results are expected from the combination of different methods of preoperative, intraoperative, and postoperative radiotherapy with chemotherapy; the cumulative effect of radiosensitization and cytotoxicity can bring about both local control and treatment of the general disease. In addition, the combination of hypoxic cell radiosensitizers and IORT, a source of important cellular hypoxia as a result of single doses, appears promising. - Lastly, randomized studies in a larger number of patients with objectives and methodologies to be perfected will document the actual contribution of IORT to an increase in survival as part of an overall treatment strategy for digestive tumors. At present, the prognosis remains significantly related to systemic metastatic evolution; this can only be influenced by chemotherapy, whose efficacy remains to be demonstrated. As means for better control of systemic disease are discovered, the clear benefits of local control via IORT will assume increased importance.

Clinical application of low dose-rate brachytherapy combined with simultaneous mild temperature hyperthermia

BACKGROUND

Recent biological research has shown that mild temperature hyperthermia (MTH) around 41 degrees C simultaneously combined with low dose-rate irradiation (LDRI) is an effective treatment modality for cancer. The aim of the study was to assess the clinical usefulness of a combination of MTH and simultaneous low dose-rate brachytherapy.

MATERIALS AND METHODS

Seven superficial and 8 deep-seated tumors were included in this protocol. Two tumors had no previous treatment and the remainder were recurrent tumors which had arisen from previously treated sites. The average major diameters of superficial and deep tumors were 8.6 and 7.0 cm, respectively. The average values for Tmin in superficial and deep tumors were 41.5 and 40.7 degrees C, respectively. Brachytherapy was delivered by 137Cs and/or 192Ir LDRI sources.

RESULTS

For superficial tumors, six of the seven tumors responded to the treatment (4 achieved CR, 2 PR, 1 NC) and four tumors did not recur within the follow-up period of 5-15 months. All of the deep tumors responded and 5 achieved CR, 3 PR. Four tumors recurred 4-17 months after the treatment and the remainder showed no local recurrence within the follow-up period of 4-31 months.

CONCLUSION

MTH simultaneously combined with LDRI was an effective method for treating progressive and bulky tumors with a previous treatment history.

Staging laparoscopy promotes increased utilization of postoperative therapy for unresectable intra-abdominal malignancies

Staging laparoscopy avoids unnecessary laparotomies in patients with unresectable intra-abdominal malignancies. However, the postoperative oncologic treatment of these patients has not been documented. This study compares rates and timing of postoperative chemotherapy (ChT) and/or radiation therapy (XRT) in patients with unresectable intra-abdominal malignancies initially evaluated by staging laparoscopy (SL) or exploratory laparotomy (EL). The records of patients surgically evaluated for esophageal, gastric, hepatobiliary, and pancreatic cancers or abdominal lymphoma were retrospectively reviewed. Data gathered included type of exploration (SL or EL), resectability, whether postoperative cancer treatment was given (ChT, XRT, or both), and the time from surgery to the beginning of such treatment. This study includes only patients with unresectable malignancies. Twenty-one patients underwent SL and 58 EL. Sixteen of the SL patients (76%) and 25 of the EL patients (43%) received postoperative cancer treatment (P = 0.009). The median number of days from surgery to postoperative cancer treatment was 13 days (range 5 to 41 days) for the SL group and 35 days (range 16 to 89 days) for the EL group (P = 0.0004). We conclude that patients with unresectable intra-abdominal malignancies discovered by SL are more likely to receive postoperative ChT and/or XRT than patients surgically evaluated by EL. Further studies to determine whether this better utilization of postoperative treatment results in better outcomes in these patients are needed.

Scintigraphy and radionuclide therapy with [indium-111-labelled-diethyl triamine penta-acetic acid-D-Phe1]-octreotide

Peptide receptor scintigraphy with [111In-DTPA-D-Phe1]-octreotide is a sensitive and specific technique to show in vivo the presence and abundance of somatostatin receptors on various tumours. With this technique primary tumours and metastases of neuroendocrine cancers as well as of many other cancer types can be localised. This technique is currently used to assess the possibility of peptide receptor radionuclide therapy with repeated administrations of high doses of [111In-DTPA-D-Phe1]-octreotide. 111In emits Auger and conversion electrons having a tissue penetration of 0.02 to 10 microns and 200 to 500 microns, respectively. Twenty end-stage patients, mostly with neuroendocrine progressing tumours, were treated with [111In-DTPA-D-Phe1]-octreotide, up to a maximal cumulative patient dose of about 74 GBq, in a phase I trial. Results showed there were no major clinical side-effects after up to 2 years treatment, except that in a few patients a transient decline in platelet counts and lymphocyte subsets occurred. Promising beneficial effects on clinical symptoms, hormone production and tumour proliferation were found. Of the 16 patients who received a cumulative dose of more than 20 GBq, 5 patients showed stabilisation of disease and 5 other patients a reduction in size of tumours. There is a tendency towards better results in patients whose tumours have a higher accumulation of the radioligand. In conclusion, peptide receptor radionuclide therapy is feasible, also with 111In as radionuclide. Theoretically, depending on the homogeneity of distribution of tumour cells expressing peptide receptors, beta-emitting radionuclides, e.g. 90Y, labelled to DOTA-chelated peptides may be more effective than 111In for peptide receptor radionuclide therapy. The first peptide receptor radionuclide therapy trials with [90Y-DOTA-Tyr3]-octreotide started recently.

Paclitaxel and concurrent radiation therapy for locally advanced adenocarcinomas of the pancreas, stomach, and gastroesophageal junction

An effective locoregional therapy is needed for adenocarcinomas of the pancreas, stomach, and gastroesophageal junction. Paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) may enhance the effect of radiation therapy (RT). Paclitaxel synchronizes cells at G2/M, a relatively radiosensitive phase of the cell cycle. We have shown that response to paclitaxel and concurrent RT (paclitaxel/RT) was not affected by p53 mutations in non-small cell lung cancer. This finding suggested that paclitaxel/RT was a rational treatment approach for other malignancies that frequently harbor p53 mutations, such as upper gastrointestinal malignancies. We completed a phase I study of paclitaxel/RT for locally advanced pancreatic and gastric cancer. The maximum tolerated dose of paclitaxel was 50 mg/m2/wk for 6 weeks with abdominal RT. The dose-limiting toxicities were abdominal pain within the radiation field, nausea, and anorexia. Phase II studies are now under way. Twenty-five patients with locally advanced pancreatic cancer have been entered at the phase II dose level of paclitaxel 50 mg/m2/wk with concurrent RT (total dose, 50 Gy). Thus far, the only grade 3/4 toxicities have been hypersensitivity reactions (n = 2), asymptomatic grade 4 neutropenia (n = 3), and nonneutropenic biliary sepsis (n = 1). Of the first 18 assessable patients with pancreatic cancer treated on the phase II study, six obtained a partial response, for a preliminary response rate of 33%. In the phase II study for locally advanced gastric cancer, 20 patients have been enrolled. Of the first 19 patients who have completed treatment, nine (47%) had grade 3/4 toxicities, including nausea, anorexia, esophagitis, and gastritis. Of the first 16 patients with gastric cancer, complete and partial responses have been observed in one and eight patients, respectively, for a preliminary response rate of 56%. We have also completed treatment on 24 patients with potentially resectable adenocarcinomas of the gastroesophageal junction with neoadjuvant paclitaxel 60 mg/m2 and cisplatin 25 mg/m2, weekly for 4 weeks, with concurrent RT (total dose, 40 Gy) followed by surgical resection. Ten patients (41%) had grade 3/4 toxicities, including neutropenia, nausea, and dehydration. Of 24 patients, four complete responses (17%) and 14 partial responses (58%) were observed, for an overall response rate of 75%. Severe esophagitis was uncommon, making this a well-tolerated outpatient regimen for adenocarcinomas of the distal esophagus. These findings demonstrate that paclitaxel-based chemoradiation for locally advanced upper gastrointestinal malignancies is well-tolerated with substantial activity.

An early phase II study of intratumoral P-32 chromic phosphate injection therapy for patients with refractory solid tumors and solitary metastases

BACKGROUND

In this early Phase II study, the authors investigated the efficacy of intratumoral injection of P-32 chromic phosphate in 17 patients with refractory solid tumors or solitary metastases in terms of response rates and overall survival.

METHODS

Seventeen patients (median age, 60 years) with either cytostatic drug-resistant tumors or tumors known to be primarily chemotherapy-resistant were entered into the study. After sonographic determination of the tumor volume, P-32 chromic phosphate (74-555 MBq) was injected into the central part of the tumor under sonographic guidance. Follow-up investigations included serial scintigraphy, sonographic examinations, and hematologic studies.

RESULTS

Injection of P-32 chromic phosphate into refractory tumors resulted in remarkable regression. The median survival of all patients was 13 months (range, 8-25 months). The response rate was 71% (12 patients). A complete remission was seen in 7 patients (41%), and the rate of partial remissions was 29% (5 patients). However, 5 patients (30%) did not respond to the treatment. In one patient thrombocytopenia was observed, but no other side effects were apparent. Important pathologic and anatomic changes within the tumor tissue were demonstrated in solitary liver metastases of gastrointestinal malignancies excised in second-look operations. In all cases examined, formation of a cyst within the area of central activity, surrounded by a centrifugal necrotic ring and a marginal fibrotic structure, was found.

CONCLUSIONS

Lack of persistent systemic or local side effects, as well as noteworthy efficacy, are properties of this optimal regional treatment modality with P-32 chromic phosphate. This modality deserves consideration for further clinical trials.

Anatomic variation of extrahepatic biliary tree structures: importance in treatment planning for radiation therapy

PURPOSE

To demonstrate the variable location of biliary tree components and to assess two treatment planning rules of thumb used for locating porta hepatic nodes for radiation therapy.

MATERIALS AND METHODS

The distance of the common hepatic duct bifurcation and duodenal papilla from adjacent vertebral bodies was measured on 34 cholangiograms, and their relationships to particular vertebral body levels were recorded. Adequacy of treatment volume to encompass porta hepatic lymph nodes was evaluated in 30 of these cholangiograms by constructing radiation portals according to the two rules of thumb.

RESULTS

Location of the common hepatic duct bifurcation and duodenal papilla varied widely. The treatment portal encompassed 13% (four of 30) of cases when the first rule of thumb was used and 80% (24 of 30) of cases when the second rule of thumb was used.

CONCLUSION

The wide variability of location of extrahepatic biliary tree structures suggests the need for individualized treatment planning so that sensitive and dose-limiting healthy tissues can be optimally excluded from radiation treatment portals. Computed tomography and other imaging modalities enable precise location of biliary tree components for radiation treatment planning.

[Radiation injuries of the small intestine. Surgical treatment]

From 1978 to 1992, 55 patients (48 women: 87%) with a mean age of 62 years (35-89) underwent 70 operations for radiation injury of the small bowel. Primary pathology treated with radiotherapy was gynecologic cancer (40: 72%), digestive malignancy (9: 16%), male genital cancer (4: 7%), carcinoma of the bladder (2: 3%). External radiation was performed alone (47: 85.5%) or associated with intracavitary radium or cesium (8: 14.5%), mean radiation dose was 50 Gy for 35 patients and not specified for 20 but greater than 45 Gy for all patients. Fifteen patients had associated chemotherapy. Latent period between radiation injury and first symptoms was 39 months (1-16 years) and 72 months (3-26 years) between radiation and surgical treatment. There were 28 solitary lesions (mean length: 148.5 cm) with 5 associated colonic injuries, 27 multiple lesions of the small bowel (mean length: 187.5 cm) with 21 associated colonic injuries. Twenty-one lesions of the abdominal wall and 13 lesions of the urinary tract were also associated. Nineteen patients had pre-operative total parenteral nutritional assistance. Surgical treatment was performed for chronic obstruction in 46 patients, for fistulae in 5 or for an acute complication in 4 (perforating peritonitis: 3, occlusion: 1). Operations performed were: small bowel resection (32), associated with bypass (2); internal by-pass (15); dissection of adhesions and/or stomy (7).

RESULTS

Operative mortality was 2 (6.2%). Morbidity occurred in 16 (29%) with 3 anastomotic fistulae. Functional results were good for 36 patients (24 resections, 7 by-pass), poor for 2 (1 resection). Failure leading to a second operation occurred in 15 (5 resections, 8 by-pass).

COMMENTS

1) pre-operative nutritional assistance improves operative results; 2) intestinal resection is preferable to internal by-pass whenever it can be performed without extreme risk or unacceptable sequelae.

[Accelerated radiotherapy: initial results in a series of locally very advanced carcinomas of the upper respiratory and digestive tracts]

From 1992 to 1993, 46 patients with very locally advanced (74% T4) head and neck carcinomas and extensive cervical involvement (82% N2-3) were treated at the Institute Gustave Roussy with a very accelerated radiotherapy regimen: 62 Gy in three weeks with two daily 1.75 Gy fractions. Early mucosal reactions were severe but manageable in this population of patients with frequent alteration of initial performance status. Nearly every patient experienced a grade 3 or 4 (WHO) mucositis and 80% required tube feeding. Follow-up is not sufficient to draw firm conclusion about late reactions but they do not seem different from those induced by conventional radiotherapy. The overall 2-year survival rate of 49.4% and loco-regional control rate of 67% seem superior to the results of conventional radiotherapy for such advanced tumors. These results have led to a multi-center randomized controlled trial comparing this regimen of accelerated radiotherapy with conventional fractionated radiotherapy.

Restorative effect of romurtide for thrombocytopenia associated with intensive anticancer drug treatment and/or irradiation in patients with gastrointestinal cancer

In 55 gastrointestinal cancer patients the mean change ratios for platelets were, respectively, 1.22 +/- 0.75 and 0.67 +/- 0.45, in the romurtide administration (30 cases) and non-administration (25 cases) groups, [statistically significant difference (p < 0.005)]. The number of cases in each group with a decrease in platelet count was 13 (43%) and 20 (80%) with and without romurtide, respectively. The difference was statistically significant, (p < 0.01). In addition, the number of cases with a marked decrease ( < 6 x 10(4)/mm3) in platelet count was 2 (7%) and 7 (28%) with and without romurtide, respectively, reaching statistical significance (p < 0.05). For patients treated with a bolus administration of 450 mg/m2 carboplatin (27 cases), the mean change ratios for leukocytes and platelets in the romurtide administration group (13 cases) were 1.10 +/- 0.52 and 1.23 +/- 0.59, respectively. Meanwhile, in the romurtide non-administration group the mean change ratios for leukocytes and platelets were, respectively, 0.74 +/- 0.27 and 0.74 +/- 0.42, a statistically significant reduction (p < 0.05) compared with the romurtide administration group. The number of cases with an increase in the number of lymphocytes after i.v. administration was significantly more than that observed after s.c. administration (p < 0.01). These results indicate that romurtide has a restorative effect on thrombocytopenia similar to that displayed for leukocytopenia when given as concomitant therapy with anticancer drugs and/or irradiation in patients undergoing intensive treatment for gastrointestinal cancer.

[Whole abdominal irradiation for peritoneal dissemination of alimentary tract cancers]

Between January 1986 and August 1991, 19 patients with alimentary tract cancers complicated by peritoneal dissemination received whole abdominal irradiation combined with intraperitoneal chemotherapy postoperatively. Using a moving-strip technique of irradiation, 12.0 Gy was delivered in three fractions to the entire abdominal contents with partial liver and kidney shielding. The primary tumor sites were the stomach in 12 patients, the colorectum in five, and the gall bladder in two. Nine patients with gross residual disease also received a limited field boost of 30.6 Gy in 17 fractions after completion of treatment to the whole abdomen. None of the patients failed to complete the planned dose despite acute gastrointestinal toxicity (nausea and vomiting, 84%, diarrhea and cramping, 78%) and acute hematologic toxicity (leukocytopenia, 84%, thrombocytopenia, 68%). Our follow-up study revealed that the actuarial one-year survival rate was 28.4% and the median survival time was 9.0 months. Survival rates at one-year for patients with colorectal and gastric cancer were 75.0% and 16.7%, respectively. Patients with gastric cancer (n = 12) had a poorer outcome than those with colorectal cancer (n = 5) in the present study. One reason for this difference may have been the presence of cancerous pleuritis, which was frequently observed in patients with gastric cancer. Therefore, more intensive treatment to prevent cancerous pleuritis seems to be necessary to improve the efficacy of whole abdominal irradiation.

[Radioimmunotherapy of malignant diseases. Value and prospects]

Radioimmunotherapy is based on the use of radioactive agents (iodine 131, yttrium 90...), murine-derived monoclonal antibodies and specific tumour-related membrane antigens. This new treatment modality was applied in 800 patients with different types of malignant tumours which had not responded to traditional therapy. Among the haematologic tumours, the most promising results were obtained in B phenotype non-Hodgkin lymphoma. More modest results were obtained for solid tumours although good results were observed after intraperitoneal administration in patients with cancer of the ovary. The main side effects are acute reversible anaphylactic shock, haematologic toxicity and development of anti-murine human antibodies. Several methods are currently under study to increase irradiation dose delivered at the tumoural site since less than 1% of the injected radioactive dose is absorbed by tumoural cells. Several clinical studies are to be conducted in France, particularly for malignant non-Hodgkin lymphoma and cancer of the ovary.

The spectrum of 5-fluorouracil cardiotoxicity

OBJECTIVE

To report three cases of cardiotoxicity related to the administration of 5-fluorouracil (5-FU) in patients with cancer.

CLINICAL FEATURES

Three patients with gastrointestinal malignancies were being treated with combined radiotherapy and chemotherapy regimens. Two patients developed myocardial ischaemia and the other a ventricular arrhythmia in association with 5-FU administration.

INTERVENTION AND OUTCOME

All patients survived the cardiac event. No patient was rechallenged with 5-FU. Radiotherapy was continued, achieving a good tumour response.

CONCLUSION

Cardiotoxicity is rarely reported with 5-FU. The cardiac events can be life threatening. It is difficult to predict which patients will be affected. Clinicians need to be aware of this potential toxicity and monitor patients appropriately.

Adjuvant therapy for gastrointestinal cancer

Perioperative adjuvant treatment with chemotherapy or radiation therapy has been investigated for colon, rectal, gastric, esophageal, and pancreatic cancers. To date, conclusive benefit had been shown only for colon and rectal cancers. Demonstration that adjuvant therapy can result in reductions in tumor recurrence and cancer death after surgery for large bowel cancer is a major therapeutic advancement, and current clinical trials may yield further incremental improvements. Standard recommendations for adjuvant treatment exist for patients with colorectal cancers who do not take part in these clinical studies. Several factors complicate the assessment of adjuvant therapy for gastric, esophageal, and pancreatic cancers. Some regimens have appeared to offer promise of improved postsurgical outcome, but no adjuvant treatment has established benefit in these sites.

Endoscopic laser coagulation of radiation-induced mucosal vascular lesions in the upper gastrointestinal tract and proximal colon

Endoscopic laser coagulation effectively controls bleeding from radiation-induced rectal vascular lesions.

OBJECTIVE

To assess the outcome of endoscopic treatment of radiation-induced bleeding due to vascular lesions located proximal to the sigmoid colon.

METHODS

We identified 15 consecutive patients with such proximal radiation enteropathy treated at our Institution with Nd:YAG laser between 1984 and 1991. Ten patients (66%) had gastric and/or small bowel involvement, and five (33%) had colonic involvement with or without more proximal lesions. Bleeding first appeared at a mean of 21.2 +/- 12.5 months after completion of radiotherapy. Mean duration of gastrointestinal bleeding before laser treatment was 7.6 +/- 4.6 months.

RESULTS

After completion of laser therapy, bleeding ceased in nine (60%) patients, decreased in three (20%), and persisted in three (20%). The mean hemoglobin level increased from 8.4 +/- 0.5 g/dl to 10.4 +/- 0.6 g/dl after completion of laser treatments (p < 0.02). The mean number of transfusions per patient per year decreased from 10.5 +/- 2.8 to 0.9 +/- 0.7 (p < 0.01). No treatment-related complications or deaths occurred.

CONCLUSIONS

Endoscopic laser coagulation of radiation-induced mucosal vascular lesions in the upper gastrointestinal tract and proximal colon appears to be safe and, in most cases, effective.

Nursing diagnoses and functional health patterns in patients receiving external radiation therapy: cancer of the digestive organs

A descriptive study using clinical methodology was conducted to identify and describe core and site-specific symptoms reported by 15 patients with cancer of the digestive organs who received external radiation therapy. A 47-item Radiation Symptom Scale was designed by the investigators for this study. Symptoms identified by patients with a mean occurrence of at least "sometimes" were considered potential defining characteristics and were submitted to a panel of experts for identification of nursing diagnoses. Seventeen nursing diagnoses, with their associated defining characteristics, were identified and classified within eight Functional Health Patterns (FHP). Half of the nursing diagnoses were formulated within the Nutritional-Metabolic and Elimination patterns. Four of the FHPs were related to primarily functional patterns; four were primarily psychological-behavioral. Results of the study describe the nursing needs of patients who receive radiotherapy to the digestive organs.

[First results of high-dose-rate 192-Iridium afterloading method applied alone or associated with laser therapy in tumors of the respiratory and digestive tracts]

High-dose-rate short-term brachytherapy with 192iridium, preceded by laser therapy if practicable, has been applied in an interdisciplinary collaboration for more than one year at our hospital. Until April, 1985, 127 applications have been made in 49 patients suffering from tumors of the respiratory and upper digestive tract. The palliative effects obtained (74% and 86%, respectively) correspond with those achievable by percutaneous radiotherapy. The local control rates can possibly be improved by an 192iridium boost in the course of a curative radiotherapy.

[Radiation therapy of malignancies of the digestive organs]

Malignancies of digestive organs have been treated, as a first choice, by surgery, and conventional fractionated radiotherapy has been palliatively applied to those inoperable or recurrent cases. IOR and intracavitary radiotherapy, which made it possible to give large dose of well localized irradiation to the lesions, are now available in combination with surgery or on its own. Here mentioned the IOR of pancreas, biliary tract, stomach and rectum, and also discussed the intracavitary radiotherapy of esophagus and biliary tract.

Local control and survival in locally advanced gastrointestinal cancer

When conventional modalities (external beam irradiation and chemotherapy +/- resection) are used in the treatment of locally advanced gastrointestinal malignancies, although useful palliation can be achieved in many patients, local control and long-term survival are infrequent. In recent trials, investigators have used fractionated external beam doses of 4500-5000 rad in 180 rad fractions in combination with irradiation boost techniques of intraoperative electrons, or intraoperative or transcatheter brachytherapy (+/- chemotherapy and resection). With colorectal and biliary cancer, both local control and long-term survival appear to be improved, compared to results achieved with conventional treatment. With pancreatic cancer, an apparent improvement has been noted with local control and median survival, but long-term survival has not been altered. For partially resected gastric cancer, the use of intraoperative irradiation has yielded five year survival rates of approximately 20%. With unresectable or residual gastric cancer, accelerated fractionation alone or in combination with chemotherapy has yielded excellent local control, but patients have died as a result of abdominal failure or lung metastases. Prevention of abdominal failures will be necessary to improve long-term survival with pancreatic and gastric cancer. Randomized trials by site are needed to determine if the observed differences seen in prospective nonrandomized trials are real or due to differences in case selection.

[Radiotherapy for carcinoma of digestive organs]

Clinical results of intraoperative radiotherapy (IOR) applied to carcinomas of the stomach, pancreas, and rectum were reported. In stomach cancer, the 5-year survival rates of patients treated by operation alone were 93.0% for stage I, 61.2% for stage II, 36.8% for stage III and 0% for stage IV. On the other hand, the 5-year survival rates of patients treated by IOR were 90.2% for stage I, 77.0% for stage II, 54.4% for stage III and 15.3% for stage IV. It has been demonstrated that IOR has definite effects on locally advanced gastric cancer. In pancreatic cancer, the median survival times for all patients treated by operation alone, IOR and IOR+ external beams were 3.5 months, 4.5 months and 8 months respectively. The median survival times of stage III patients treated by operation alone, IOR and IOR+ external beams were 5.5 months, 5.5 months and 12 months respectively. Our clinical results suggest that prolongation of life can be expected in patients who are treated by IOR followed by external beams and stage III is best indicated. In rectal cancer, it was found that stage IV as classified according to the rules for colorectal cancer studies in Japan is best indicated for IOR from the analysis of the survival figures. In stage IV patients, those who received operation alone could not survive more than 50 months while about 50% of those who were treated by IOR are alive 50 months after the treatment.

[Results of radio-surgical treatment of primary malignant lymphomas of the digestive tract]

In 29 patients treated in the Department of radiotherapy of the University Hospital, Lausanne, between 1963 to 1978, 18 of these lesions were localized in the stomach (1 was confined to the oesophago-gastric region), 10 in the small intestine and 1 in the rectum. The patients comprised 18 men and 11 women; the majority (21 out of 29) were over 50 years of age. Using the former histological classification, 13 patients had lymphomas of the lymphocytic type (in which 1 was a Brill-Symmers), 13 had reticulum cell sarcomas and 3 had mixed type. 28 patients had previously undergone surgery: 7 had had extensive surgery, 15 resections were classified as macroscopically tumour free by the surgeons though histologically the end of the surgical specimens was sectioned through tumour and/or regional lymphatics were positive, and 6 patients had undergone exploratory laparotomies. Radiotherapy was carried out using high energy machines in 28 of the 29 patients (i.e. telecobalt therapy and a betatron) and in the remaining patient a 200 kV conventional therapy machine was used. 21 patients received radical radiotherapy (in 15 patients the irradiation was confined to the tumour bed and the regional lymphatic ganglia, 1 patient was treated over the whole abdominal cavity using various parallel opposing portals, and 5 patients were treated by the moving-strip technic). In 8 patients the treatment was considered incomplete. The patients who were treated radically received doses of 4000-4500 rads in 5 weeks to the tumour bed and the regional lymphatic ganglia, and 2000-2500 rads in 5 weeks when the moving-strip technic was used and when the whole abdominal cavity was treated. Seven patients also received chemotherapy involving either one drug or in some cases multiple drug therapy. The best survival figures were in patients treated radically by both surgery and radiotherapy regardless of histology. The only prognostic factor was the initial extent of the disease.