Radiographic features predictive of recurrence and survival after surgical resection of perihilar cholangiocarcinoma

Objective

To study which radiographic features were associated with recurrence and adverse outcome in patients undergoing surgical resection of perihilar cholangiocarcinoma (PCCA), as well as to evaluate the imaging patterns that signify recurrence after the resection of PCCA.

Materials and methods

This study was conducted in a solitary tertiary center and utilized a retrospective, analytical, case-control design. The study population consisted of patients with pathologically confirmed PCCA who underwent surgical resection and were subsequently followed up from January 2009 to December 2017. A total of 77 patients were enrolled in the study and were categorized into two distinct groups, namely recurrent and non-recurrent. The analysis encompassed the examination of demographic data and recurrence patterns. Additionally, survival and multivariate analyses were employed to assess radiographic imaging data and surgical information.

Results

Seventy-seven patients diagnosed with PCCA based on pathological evidence were included in the study. Among the participants, there were 28 females and 49 males, with ages ranging from 41 to 81 years (mean age of 60.65 ± 7.66). A noteworthy finding was the recurrence rate of 65 % observed following surgical resection. The presence of regional lymph node (LN) metastasis, adjacent organ invasion, and surgical margin emerged as the three independent factors that exhibited a significant association with recurrence after post-operative resection (p = 0.023, p = 0.028, and p = 0.010, respectively). The patients with PCCA who experienced regional LN metastasis had a median overall survival (OS) of 22 months, which was significantly lower than the 46 months observed in those without regional LN metastasis (p < 0.018). Furthermore, the individuals with regional LN metastasis had a death rate that was 2.08 times higher than those without (p = 0.040). In addition, those with adjacent organ invasion had an OS duration of 21 months compared with 52 months in those without (p = 0.008), and the rate of death was 2.39 times higher (p = 0.018). Patients with an R1 resection margin had an OS duration of 36 months compared with 51.56 months in those with an R0 resection margin (p = 0.006), as well as a 2.13 times higher rate of recurrence (p = 0.010) and a 2.43 times higher mortality rate (p = 0.013).

Conclusion

The presence of regional LN metastasis, invasion of adjacent organs, and R1 resection margin were identified as distinct factors that are linked to both disease recurrence and reduced OS. Local recurrence, as well as the spread of cancer to distant organs such as the lungs and liver, were frequently observed patterns of recurrence. To enhance the precision of staging, prognosis, and treatment, the inclusion of periductal fat or invasion of adjacent organs should be considered in the staging system for PCCA.

Trends in Anticoagulant Utilization and Clinical Outcomes for Cancer-Associated Thrombosis: A Multicenter Cohort Study in Thailand's Upper-Middle-Income Country Setting

PURPOSE

To evaluate anticoagulant trends and clinical outcomes in the management of cancer-associated thrombosis (CAT) within Thailand, an upper-middle-income country (UMIC).

METHODS

This multicenter retrospective cohort study included adult patients with cancer diagnosed with venous thromboembolism (VTE) hospitalized in Thailand from 2017 to 2021. Anticoagulants were classified as low-molecular-weight heparin (LMWH), direct oral anticoagulants (DOACs), and warfarin. Prescription trends were assessed, and patients were followed for 1 year, or until 2022 to evaluate outcomes. The primary effectiveness outcome was recurrent VTE, whereas the primary safety outcome was major bleeding. Secondary outcomes included net clinical benefit and all-cause mortality. Treatment effects were examined using inverse probability of treatment weighting (IPTW) Cox proportional hazards models.

RESULTS

Among 1,611 patients (61.3% female; mean age, 58.8 years; standard deviation, 13.1 years), 86% received LMWH, 10% warfarin, and 4% DOACs. In the study cohort, LMWH prescriptions remained consistent, warfarin use declined, and DOAC prescriptions notably increased. In IPTW analysis, DOACs showed comparable rates of VTE recurrence (weighted hazard ratio [HR], 0.77 [95% CI, 0.22 to 2.70]; P = .679) and major bleeding (weighted HR, 0.62 [95% CI, 0.15 to 2.55]; P = .506) with LMWH. Warfarin had a higher risk of major bleeding (weighted HR, 2.74 [95% CI, 1.12 to 6.72]; P = .028) but a similar rate of VTE recurrence (weighted HR, 1.46 [95% CI, 0.75 to 2.84]; P = .271) compared with LMWH. Secondary outcomes were consistent across groups.

CONCLUSION

LMWH remains the primary treatment for CAT, in line with current guidelines. The study highlights the challenges faced in these settings with the continuous use of warfarin. The comparable efficacy and safety of DOACs with LMWH suggest a potential shift in CAT management within UMICs.

Preoperative controlling nutritional status (CONUT) score is an independent prognostic factor in cholangiocarcinoma patients treated with hepatectomy

Background

Nutritional status is one of the important factors determining the short- and long-term outcomes of surgery in cancer. This study aimed to assess the prognostic role of preoperative controlling nutritional status (CONUT) score in intrahepatic cholangiocarcinoma (iCCA) patients.

Methods

A total of 101 iCCA patients who underwent hepatectomy between 2015 and 2018 at the Srinagarind Hospital, Khon Kaen University, were included in this retrospective study. Patients were classified according to the CONUT score. Univariate and multivariate analyses were performed to determine the correlation between clinicopathological features and overall survival.

Results

Patients were categorized into normal nutrition (n = 40 or 39.5%), mild (n = 54 or 53.5%), and moderate-severe malnutrition (n = 7). Patients with high CONUT scores had significantly shorter survival (HR 2.55, 95% CI 1.04-6.25, p = 0.04). In multivariable analysis, tumor size (HR = 2.58, p < 0.01), the growth pattern of mass forming combined with periductal (HR = 4, p < 0.01), lymph node metastasis (HR = 7.20, p < 0.01) and high CONUT score (HR = 4.71, p = 0.01) were independent factors for poor survival of iCCA patients.

Conclusion

The preoperative CONUT score is a simple prognostic factor to predict the outcomes of iCCA patients undergoing hepatectomy.

Programmed death‑ligand 1 expression in tumor cells and tumor‑infiltrating lymphocytes are associated with depth of tumor invasion in penile cancer

The present study aimed to demonstrate the proportion of the programmed death-ligand 1 (PD-L1) expression in penile cancer patients and the association with clinicopathological parameters. Formalin-fixed paraffin-embedded specimens were obtained from 43 patients with primary penile squamous cell carcinoma treated at Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, between 2008 and 2018. PD-L1 expression was evaluated by the immunohistochemistry using an SP263 monoclonal antibody. PD-L1 positivity was defined as >25% tumor cell staining or >25% tumor-associated immune cell staining. The correlation between PD-L1 expression and clinicopathological parameters was analyzed. A total of eight of 43 patients (18.6%) were identified as positive for PD-L1 expression in tumor cells and tumor-infiltrating lymphocytes. In the PD-L1 positive group, there was a significant association with pathological T stage (P=0.014) with a higher percentage of PD-L1 positive tumors in T1 stage compared with T2-T4 stage. In this cohort, there was a trend towards longer survival in patients with positive PD-L1 expression (5-year OS: 75% vs. 61.2%, P=0.19). Lymph node involvement and the location of tumor at the shaft of penis were two independent prognostic factors for survival. In conclusion, the PD-L1 expression was detected in 18% of penile cancer patients and high expression of PD-L1 was associated with the early T stage.

Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, staging and treatment of patients with metastatic breast cancer

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, staging and treatment of patients with metastatic breast cancer (MBC) was published in 2021. A special, hybrid guidelines meeting was convened by ESMO and the Korean Society of Medical Oncology (KSMO) in collaboration with nine other Asian national oncology societies in May 2022 in order to adapt the ESMO 2021 guidelines to take into account the differences associated with the treatment of MBC in Asia. These guidelines represent the consensus opinions reached by a panel of Asian experts in the treatment of patients with MBC representing the oncological societies of China (CSCO), India (ISMPO), Indonesia (ISHMO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), the Philippines (PSMO), Singapore (SSO), Taiwan (TOS) and Thailand (TSCO). The voting was based on the best available scientific evidence and was independent of drug access or practice restrictions in the different Asian countries. The latter were discussed when appropriate. The aim of these guidelines is to provide guidance for the harmonisation of the management of patients with MBC across the different regions of Asia, drawing from data provided by global and Asian trials whilst at the same time integrating the differences in genetics, demographics and scientific evidence, together with restricted access to certain therapeutic strategies.

Systemic Treatment for Cholangiocarcinoma

Cholangiocarcinoma (CCA) is a diverse group of epithelial cancers that affect the biliary tree. The incidence of CCA is low in Western countries but significantly higher in endemic regions such as China and Thailand. Various risk factors contribute to the development of CCA. Recent studies have revealed molecular alterations in biliary tract cancers, providing insights into cholangiocarcinogenesis and potential targeted therapies. Surgical resection is the primary curative treatment for CCA. Adjuvant chemotherapy has been extensively studied, and some regimens have proven to be beneficial. Neoadjuvant chemotherapy has shown potential benefits in select cases, but its role remains controversial. In advanced stages, chemotherapy is the standard of care, and molecular profiling has identified potential targets such as FGFR, IDH1, HER2, and other tumor-agnostic therapies. Immunotherapy has demonstrated limited benefit in advanced CCA. This chapter provides an overview of the current evidence and ongoing research evaluating various chemotherapy regimens, targeted therapies, and immunotherapies across different stages of CCA.

An Exploration of Heart Failure Risk in Breast Cancer Patients Receiving Anthracyclines with or without Trastuzumab in Thailand: A Retrospective Study

Anthracycline-based regimens with or without anti-human epidermal growth factor receptor (HER) 2 agents such as trastuzumab are effective in breast cancer treatment. Nevertheless, heart failure (HF) has become a significant side effect of these regimens. This study aimed to investigate the incidence and factors associated with HF in breast cancer patients treated with anthracyclines with or without trastuzumab. A retrospective cohort study was performed in patients with breast cancer who were treated with anthracyclines with or without trastuzumab between 1 January 2014 and 31 December 2018. The primary outcome was the incidence of HF. The secondary outcome was the risk factors associated with HF by using the univariable and multivariable cox-proportional hazard model. A total of 475 breast cancer patients were enrolled with a median follow-up time of 2.88 years (interquartile range (IQR), 1.59-3.93). The incidence of HF was 3.2%, corresponding to an incidence rate of 11.1 per 1000 person-years. The increased risk of HF was seen in patients receiving a combination of anthracycline and trastuzumab therapy, patients treated with radiotherapy or palliative-intent chemotherapy, and baseline left ventricular ejection fraction <65%, respectively. There were no statistically significant differences in other risk factors for HF, such as age, cardiovascular comorbidities, and cumulative doxorubicin dose. In conclusion, the incidence of HF was consistently high in patients receiving combination anthracyclines trastuzumab regimens. A reduced baseline left ventricular ejection fraction, radiotherapy, and palliative-intent chemotherapy were associated with an increased risk of HF. Intensive cardiac monitoring in breast cancer patients with an increased risk of HF should be advised to prevent undesired cardiac outcomes.

Clinical and Immunologic Responses to a B-Cell Epitope Vaccine in Patients with HER2/neu-Overexpressing Advanced Gastric Cancer-Results from Phase Ib Trial IMU.ACS.001

PURPOSE

HER2/neu is overexpressed in up to 30% of gastroesophageal adenocarcinomas (GEA) and linked to poor prognosis. Recombinant mAbs to treat HER2/neu-overexpressing cancers are effective with limitations, including resistance and toxicity. Therefore, we developed a therapeutic B-cell epitope vaccine (IMU-131/HER-Vaxx) consisting of three fused B-cell epitopes from the HER2/neu extracellular domain coupled to CRM197 and adjuvanted with Montanide. This phase Ib study aimed to evaluate the optimal/safe dose leading to immunogenicity and clinical responses (https//clinicaltrials.gov/ct2/show/NCT02795988).

PATIENTS AND METHODS

A total of 14 patients with HER2/neu-overexpressing GEA were enrolled, and dose escalation (10, 30, 50 μg) was performed in three cohorts (C). Immunogenicity was evaluated by HER2-specific Abs and cellular responses, clinical responses by CT scans according to RECIST version 1.1.

RESULTS

IMU-131 was safe without vaccine-related significant local/systemic reactions or serious adverse events. A total of 11 of 14 patients were evaluable for changes in tumor size and vaccine-specific immune responses. One patient showed complete, 5 partial responses, and 4 stable diseases as their best response. HER2-specific IgG levels were dose dependent. In contrast to patients in C1 and C2, all patients in C3 mounted substantial HER2-specific Ab levels. In addition, cellular vaccine responses, such as Th1-biased cytokine ratios and reduced regulatory T cell numbers, were generated. Progression-free survival was prolonged in C3, correlating with the vaccine-specific humoral and cellular responses.

CONCLUSIONS

IMU-131 was well tolerated and safe. The induced HER2-specific Abs and cellular responses were dose dependent and correlated with clinical responses. The highest dose (50 μg) was recommended for further evaluation in a phase II trial, with chemotherapy + IMU-131 or chemotherapy alone, which is currently ongoing.

Palbociclib and beyond for the treatment of HR + HER2- metastatic breast cancer: an Asian-Pacific perspective and practical management guide on the use of CDK4/6 inhibitors

Breast cancer is the most frequent cancer amongst women worldwide including in Asia where the incidence rate is rapidly increasing. Even with treatment, around 30% of patients with early breast cancer progress to metastatic disease, with hormone receptor positive (HR+) and human epidermal growth factor receptor 2 negative (HER2-) breast cancer the most common phenotype. First-line endocrine therapy targeting the estrogen receptor signaling pathway provides a median progression-free survival or time to progression of 6-15 months in HR + HER2- metastatic breast cancer. Recently, cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitors, combined with endocrine therapy, have achieved more than two years median progression-free survival in HR + HER2- metastatic breast cancer. However, the characteristics of the Asian breast cancer population differ from those of Western populations and need to be considered when selecting a suitable treatment. Breast cancer is diagnosed at a younger age in Asian populations and late stage at presentation is generally more common in low-/middle-income countries than high-income countries. Consequently, the proportion of premenopausal women with metastatic breast cancer is higher in Asian compared with Western populations. While CDK4/6 inhibitors have been approved in the USA (FDA) since 2015, experience with them in Asia is more limited. We review the experience with the CDK4/6 inhibitor palbociclib in Asian patients with HR + HER2- metastatic breast cancer and provide guidance on the use of palbociclib in these patients.

Prognostic Factors for Penile Cancer and Survival in Response to Multimodality Therapy

Purpose

To report treatment outcomes of penile cancer in a single institution in Thailand and to identify prognostic factors for survival, highlighting the crucial role of multi-modality treatment (MMT).

Patients and Methods

Squamous cell carcinoma of penis patients who were treated at Srinagarind hospital between 2007–2015 were retrospectively analyzed. Clinical and pathological data were retrospectively reviewed. Overall survival (OS) was calculated using the Kaplan-Meier method and data were compared using the Log rank test. Cox regression analysis of factors affecting survival was conducted.

Results

A total of 70 patients were identified with a median follow-up of 69.4 months. Twenty-eight patients (40%) presented with early-stage (stage I or II), whereas 42 patients (60%) were stage III or IV disease. The median OS was 29.3 months (Interquartile range 10.5 months - not reached) for the entire cohort. Nodal involvement was the only factor identified from the multivariate model with the adjusted HR or 5.74 (95% CI 2.52–13.04). For patients with stage IIIB/IV, multi-modality treatment (MMT) resulted in longer survival when compared with surgery alone (HR 0.37; 95% CI 0.16–0.90).

Conclusion

Patients with penile cancer in Thailand presented with younger age and more locally advanced stage. Nodal involvement is the single poor prognostic factor for OS and MMT was associated with longer survival in stage IIIB/IV disease.

Crizotinib-Associated Renal Cysts in Anaplastic Lymphoma Kinase-Positive Lung Cancer Patients: A Single-Center Experience

Crizotinib is an anaplastic lymphoma kinase (ALK) inhibitor that was approved for ALK-harboring lung cancer. There have been reports about the development and progression of renal cysts from crizotinib. We report a series of 3 cases of crizotinib-associated renal cysts in patients admitted to our institution, with different kinds of presentation. A monitor for complex renal cysts is warranted in patients receiving crizotinib.

Abstract CT059: A Phase Ib open label multicenter study with a HER2/neu peptide vaccine administered with cisplatin and 5-fluorouracil or capecitabine chemotherapy shows safety, immunogenicity and clinical response in patients with HER2/Neu overexpressing advanced cancer of the stomach

Background: HER2/neu is overexpressed in 15-25% of gastric cancer patients and associated with poor prognosis. Alternative treatments to monoclonal antibodies are needed due to cost and global availability issues of mAbs. Thus a B-cell peptide vaccine (IMU-131) was developed, consisting of 3 fused B-cell epitopes (p467) from the HER2/neu extracellular domain coupled to CRM197 applied with the adjuvant Montanide. The current study evaluated the optimal and safe vaccine dose leading to immunogenicity and clinical responses.

Material & Methods: In an open-label multicenter Phase Ib trial in SE-Asia and Eastern Europe, 14 patients with HER2/neu overexpressing (++/+++) gastric or gastroesophageal junction adenocarcinoma were recruited to receive 3 injections of IMU-131 (days 0, 14, 35) in combination with chemotherapy (CT) every 21 days. Dose escalation with 10 µg, 30 µg and 50 µg was performed in 3 cohorts. Safety, immunogenicity and clinical responses were evaluated.

Results: No SAEs related to administration of IMU-131 were reported. Eleven of 14 patients were evaluable for vaccine-specific immune responses and 10 for tumor growth assessment. Higher p467- and Her-2 specific IgG levels were observed in cohort 2 (30 µg/dose) compared to cohort 1 (10 µg/dose). Two of five patients in cohort 2 showed minimal antibody titers. In contrast, all patients in cohort 3 (50µg/dose) responded to the vaccine with equally high antibody levels. Response rate was an exploratory endpoint and of 10 evaluable patients, 5 patients showed partial response and 4 patients showed stable disease. In cohort 3 the high antibody levels correlated with clinical response, while in cohort 2 only moderate correlations between humoral and clinical responses were observed. In cohort 1 partial response did not correlate with Ab levels, but rather with a high percentage of CD8 T-cells and increased inflammatory cytokine levels (high IFN-γ and TNF-α/IL-10 ratio).

Conclusions: The vaccine was well tolerated and safe with antibody responses at the highest dose (50 µg) showing a strong correlation with clinical responses. Thus, a dose of 50 µg was recommended for further evaluation in Phase II, featuring two arms of either IMU 131 plus CT or CT alone. We propose that this vaccine might be of significant medical benefit and further trials are warranted.

Citation Format: Ursula Wiedermann, Erika Garner-Spitzer, Yee Chao, Iurie Bulat, Arunee Dechaphunkul, Wichit Arpornwirat, Chaiyut Charoentum, Chia-Jui Yen, Thomas Cheung Yau, Marina Maglakelidze, Suebpong Tanasanvimon, Jedzada Maneechavakajorn, Aumkhae Sookprasert, Li-Yuan Bai, Wen-Chi Chou, Teerapat Ungtrakul, Christoph C. Zielinski, Leslie Chong, Nick Ede, Anthony J Good. A Phase Ib open label multicenter study with a HER2/neu peptide vaccine administered with cisplatin and 5-fluorouracil or capecitabine chemotherapy shows safety, immunogenicity and clinical response in patients with HER2/Neu overexpressing advanced cancer of the stomach [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr CT059.

Frailty Syndrome in Biliary Tract Cancer Patients: Prevalence and Associated Factors

Background:

Frailty, a risk of unfavorable outcomes from disability to adapt to stressors, is common in the elderly but could occur in younger patients with cancer. This study focused on the prevalence of frailty in biliary tract cancer (BTC) and associated factors.

Methods:

A total of 75 BTC patients receiving chemotherapy from January 2016 to September 2017 were enrolled. Frailty was diagnosed by the FRAIL (Fatigue, Resistance, Ambulation, Illnesses, and Loss of weight) scale. Univariate and multivariate regression analyses were used to analyze factors associated with frailty.

Results:

The prevalence rates of frailty and pre-frailty were 12% (9 cases) and 60% (45 cases). According to multivariate logistic analysis, three factors were associated with frailty, including old age, high body mass index (BMI), and history of liver surgery. The adjusted odds ratios of the factors were 1.12 (95% CI: 1.01, 1.24), 1.28 (95% CI: 1.01, 1.64), and 6.16 (95% CI: 1.11, 34.16), respectively.

Conclusion:

Frailty is not uncommon in BTC patients. Old age, high BMI, and history of liver surgery are important risk factors for frailty.

Validation of the Thai version of the family reported outcome measure (FROM-16)© to assess the impact of disease on the partner or family members of patients with cancer

BACKGROUND

Cancer not only impairs a patient's physical and psychosocial functional behaviour, but also contributes to negative impact on family members' health related quality of life. Currently, there is an absence of a relevant tool in Thai with which to measure such impact. The aim of this study was to translate and validate the Family Reported Outcome Measure (FROM-16) in Thai cancer patients' family members.

METHODS

Thai version of FROM-16 was generated by interactive forward-backward translation process following standard guidelines. This was tested for psychometric properties including reliability and validity, namely content validity, concurrent validity, known group validity, internal consistency, exploratory and confirmatory factor analysis. Construct validity was examined by comparing the Thai FROM-16 version with the WHOQOL-BREF-THAI.

RESULTS

The internal consistency reliability was strong (Cronbach's alpha = 0.86). A Negative moderate correlation between the Thai FROM-16 and WHOQOL-BREF-THAI was observed (r = - 0.4545, p < 0.00), and known group validity was proved by a statistically significant higher score in family members with high burden of care and insufficient income. The factor analysis supported both 3-factor and 2-factor loading model with slight difference when compared with the original version.

CONCLUSIONS

The Thai FROM-16 showed good reliability and validity in Thai family members of patients with cancer. A slight difference in factor analysis results compared to the original version could be due to cross-culture application.

A phase Ib/II open label study of IMU-131 HER2/Neu peptide vaccine plus cisplatin and either 5-fluorouracil or capecitabine chemotherapy in patients with HER2/Neu overexpressing metastatic or advanced adenocarcinoma of the stomach or gastroesophageal junction

TPS176

Background: Gastric cancer is the 5th most frequently diagnosed cancer and the 3rd leading cause of cancer deaths. HER2/neu is overexpressed in 15% to 25% of patients with gastric cancer and associated with a poor prognosis. Monoclonal antibodies against HER2/neu have been shown to be effective but alternative treatments are needed due to cost and global availability issues. IMU-131 is a B-cell peptide vaccine composed of 3 B cell epitopes derived from the extracellular domain of HER2/neu. Polyclonal antibodies against IMU-131 peptides binding 3 separate regions (DIII, IV) of HER2/neu have been shown to elicit antitumor activity in vitro and a phase I study demonstrated safety and immunogenicity in Her-2 +/++ metastatic breast cancer patients. Fusion of the single peptides into a hybrid peptide conjugated to CRM197 in conjunction with the adjuvant Montanide (P467-CRM-Montanide) improved formulation and stability of the vaccine. With the present Phase 1b/2 trial performed in patients with HER2/neu overexpressing gastric or gastroesophageal junction (GEJ) adenocarcinoma, we hypothesized that administration of IMU-131 in addition to chemotherapy is safe and immunogenic, and will prolong survival and may delay tumor progression and/or reduce tumor burden. Methods: This study is an international open-label multicenter study performed in 16 Asian and Eastern European sites with a maximum of 18 patients enrolled in Phase 1b. This dose escalation study is designed to assess safety, tolerability, immunogenicity and recommended phase 2 dose (RP2D) of IMU-131. Each patient is administered three injections of IMU-131, at a single dose level on Days 0, 14, and 35, accompanied by chemotherapy cycles of cisplatin and 5-fluorouracil or capecitabine every 21 days. The RP2D will be evaluated in the dose expansion Phase 2 study with 68 patients being enrolled. Results: The study is ongoing with the completion of the phase 1b portion in 4Q18. Conclusions: No conclusions can be drawn at this time. Clinical trial information: NCT02795988.

The impact of skeletal muscle mass on survival outcome in biliary tract cancer patients

Low skeletal muscle mass is frequently observed in cancer patients and is known to be a poor prognostic factor for survival outcomes. The purposes of our study were to determine the prevalence of sarcopenia and its relation to mortality in biliary tract cancer. Body composition measurements (skeletal muscle index, total fat mass, bone mineral content) were evaluated by using dual-energy x-ray absorptiometry in 75 biliary tract cancer patients before chemotherapy. Muscle strength was measured by handgrip strength and gait speed. Overall survival and its associated factors were determined. The mean appendicular muscle mass was 17.8±2.7 kg in men and 14.0±2.1 kg in women (p < 0.05). Sarcopenia was diagnosed in 46 patients (61.3%) and higher proportion of men was classified as sarcopenia than women (69.0% vs 35.3%, p < 0.05). Multivariable analysis adjusted for chemotherapy regimen and age revealed that high appendicular muscle mass independently predicted better survival outcomes (HR 0.40; 95% CI, 0.18 to 0.88; p = 0.023). Sarcopenia is common in biliary tract cancer patients and low appendicular muscle mass was associated with poor survival outcome.

Breast Cancer Incidence Trends and Projections in Northeastern Thailand

BACKGROUND

The northeast has the lowest incidence of breast cancer of all regions in Thailand, although national rates are increasing. The heterogeneity in subnational trends necessitates a comprehensive evaluation of breast cancer incidence trends and projections to provide evidence for future region-specific strategies that may be employed to attenuate this growing burden.

METHODS

Joinpoint regression and age-period-cohort modeling were used to describe trends from 1988-2012. Data was projected from three separate models to provide a range of estimates of incidence to the year 2030 by age group.

RESULTS

Age-standardized rates (ASRs) increased significantly for all women from 1995-2012 by 4.5% per year. Rates for women below age 50 increased by 5.1% per year, while women age 50 years and older increased by 6% per year from 1988-2012. Projected rates show that women age 50 years and older have the largest projected increase in ASRs by 2030 compared to younger women and all women combined.

CONCLUSIONS

Breast cancer trends in Khon Kaen are presently lower than other regions but are expected to increase and become comparable to other regions by 2030, particularly for women ages 50 years and older.

Outcomes of multidisciplinary treatment in penile cancer: Experience from Thailand

555

Background: Penile cancer is relatively more common in Thailand compared to western countries. We report multidisciplinary treatment outcomes of penile squamous cell carcinoma at a regional center in northeast of Thailand. Methods: Using an institutional database, a total of 68 patients with squamous cell carcinoma of penis treated during 2009-2015 were identified. Patient demographics, pathological data, and treatment modality were reviewed. Survival data was calculated using the Kaplan-Meier method. Results: Median age was 53 years (25-89 years) and the median follow-time was 2.7 years. At presentation, 39 patients (57.4%) were node positive, and 9 (13.2%) had metastatic disease. Management was penile preserving surgery in 13 patients, partial penectomy in 36 patients, total penectomy in 15 patients, and palliative with radiation and/or chemotherapy in 4 patients. The 3-year overall survival for patients with N0-1 and N2-3 was 86% and 35% respectively. For those with high risk (N2/N3) non-metastatic disease, multimodality treatment improved overall survival significantly compared with surgery alone (13.7 mo vs 8.6 mo; HR 0.32, p-value = 0.04) Conclusions: Patients present with locally advanced disease had a poor prognosis. Multidisciplinary management improved overall survival N2/N3 patients.

Programmed Death-Ligand 1 (PD-L1) Expression Associated with a High Neutrophil/Lymphocyte Ratio in Cholangiocarcinoma

Background: Effective treatments for cholangiocarcinoma (CCA) are still lacking. There are promising results of checkpoint inhibitor programmed cell death ligand-1 (PD-L1) activities in early phase trials. This study aimed to investigate the expression of PD-L1 and its relation to possible treatments for CCA. Methods: Formalin-fixed paraffin-embedded tumor samples from 46 patients with cholangiocarcinoma were retrieved. PD-L1 expression was evaluated by immunohistochemistry using anti-PD-L1 antibody, clone 5H1. A PD-L1 positive response on tumor cells was defined as >1% of tumor cell membranes stained. The association between PD-L1, clinico-pathological characteristics was analyzed using Fisher’s exact test, and survival analysis was done with the Cox regression model. Results: Out of 46 samples, 32 (70%) had positive PD-L1 expression in tumor cell membranes. The median level of PD-L1 expression was 1.75% (0-34.7). PD-L1 expression was significantly associated with stage IV disease (OR 3.98, p=0.046) and a high neutrophil/lymphocyte ratio (OR 5.36, p=0.018). PD-L1 positivity was associated with worse overall survival compared with those with a PD-L1 negative tumor but did not reach a level of significance (7.2 vs. 7.9 months, p=0.32). Conclusion: PD-L1 is widely expressed in CCA but was not predictive for overall survival. PD-L1 positivity was (7.2 and 7.9 months, p=0.32). Significantly associated with stage IV disease and a high neutrophil/lymphocyte ratio.

A phase II randomized double-blind placebo-controlled study of 6-gingerol as an anti-emetic in solid tumor patients receiving moderately to highly emetogenic chemotherapy

6-Gingerol is a natural compound extracted from ginger. Preclinical studies demonstrated that 6-gingerol has an anti-emetic activity by inhibiting neurokinin-1, serotonin, and dopamine receptors. Several clinical trials examined crude ginger powder for preventing chemotherapy-induced nausea and vomiting (CINV), but none of them was conducted with a standardized bioactive compound. Patients who received moderately to highly emetogenic adjuvant chemotherapy were randomized to receive 6-gingerol 10 mg or placebo orally twice daily for 12 weeks. Ondansetron, metoclopramide, and dexamethasone were given to all patients. The primary endpoint was complete response (CR) rate defined as no emesis or rescue treatment at any time. Eighty-eight patients were randomized to receive 6-gingerol (N = 42) or placebo (N = 46). Most patients received highly emetogenic chemotherapy (93%). Overall CR rate was significantly higher in 6-gingerol group as compared with that of the placebo (77 vs. 32%; P < 0.001). The difference in means of appetite score was significant (P = 0.001) and more noticeable over time. Mean FACT-G score indicating quality of life was significantly higher (86.21) in 6-gingerol group at 64 days as compared with that of placebo group (72.36) (P < 0.001). No toxicity related to 6-gingerol was observed. Patients treated with 6-gingerol reported significantly less grade 3 fatigue (2 vs. 20%; P = 0.020). 6-Gingerol significantly improved overall CR rate in CINV, appetite and quality of life in cancer patients receiving adjuvant chemotherapy. A phase III randomized study of 6-gingerol is warranted to confirm these results.

Prognostic Factors for Large Symptomatic Gists: a Pragmatic Study of Experiences From a University Hospital Over 10 Years

Background:

Gastrointestinal stromal tumors (GISTs), which are mesenchymal neoplasms in the gastrointestinal (GI) tract account for 0.2% of all GI tumors. Several factors have been reported (mostly from studies conducted in Western countries) to be associated with survival in GISTs cases such as tumor site, staging, and tumor size. We conducted a pragmatic study, looking at a 10-year period, aimed at understanding the prognostic factors related to GISTs in a university hospital. The study population consisted of patients with large symptomatic GISTs.

Methods:

This was a retrospective study conducted at the Department of Surgery in the Khon Kaen University Hospital (Thailand). All patients diagnosed with GISTs that were treated between 2006 and 2015 were consecutively enrolled. The diagnosis of GISTs was made by examining the pathological section and immunohistochemistry results. The outcome of this study was the rate of survival after surgical treatment. Prognostic factors were determined using Cox regression analysis.

Results:

There were 124 GISTs patients treated at the university hospital during the 10-year period of the study. The median age of all patients was 54 years (range 24-83 years). Of those, 119 (95.9%) were symptomatic. Rectosigmoid GISTs accounted for 20.2% of all tumors. The median tumor size was 8 cm. A total of 68 patients (54.8%) died. The median survival time for all patients was 7.18 years (1st -3rd quartile range 6.48-7.89). There were three significant factors associated with death including male gender, liver metastasis, and peritoneal metastasis.

Conclusion:

Male gender, liver metastasis, and peritoneal metastasis were prognostic factors for large symptomatic GISTs.

Hospital-based Population of Elderly Cancer Cases in Northeastern Thailand

BACKGROUND

The proportion of aged Thais (≥65 years old) is expected to be 30% by 2030, leading to an increased number of elderly cancer cases. Older individuals have distinct patterns of cancer and treatment needs. We therefore conducted the present study of new cancer cases and trends to get a perspective on the elderly cancer situation in Northeast Thailand.

MATERIALS AND METHODS

All new elderly cancer cases (≥65 years) registered in the hospital-based cancer registry at the Faculty of Medicine, Srinagarind Hospital, Khon Kaen University during 1993-2012 were included in the study.

RESULTS

Elderly patients accounted for 31.6% of all cancer patients and new cancer cases in the older age group increased 46% from the first to second decades. The absolute number of oldest old (80+ years) doubled. The top three cancers in males were liver and bile duct, lung, and colorectal. In females, the three most common cancers were liver and bile duct, oral cavity, and cervix. Cancers with the highest percentages of increase were thyroid, prostate, and colorectal.

CONCLUSIONS

Elderly cancer cases are increasing. Treatment modalities and palliative care for older populations are urgently needed.

Treatment Outcome and Predictors of Survival in Thai Adult Rhabdomyosarcoma Cases

BACKGROUND

Adult rhabdomyosarcoma (RMS) is a rare and aggressive disease with limited data compared with pediatric RMS. The goal of this study was to determine the treatment outcome and identify factors related to survival outcome in Thailand.

MATERIALS AND METHODS

Adult patients (≥15 years old) with the pathological diagnosis of RMS between 1985 and 2010 were reviewed. The data were retrospectively reviewed from the pathological results and medical records from Srinagarind Hospital, Khon Kaen University.

RESULTS

A total of 34 patients were identified in the study. The median age at diagnosis was 35.5 years and the most common primary sites were extremity and the head and neck region. The incidence of pleomorphic RMS increased with age and none was found in those aged younger than 20 years old. The median survival time was 9.33 months (95%CI: 5.6-13.1). The 1- and 5- year survival rates were 38.2% (22.3-54.0) and 20.6% (9.1-35.3). On multivariate analysis, age and size of tumor did not predict better outcome while chemotherapy and surgery were significantly associated with longer survival.

CONCLUSIONS

Outcome of adult RMS was poor. Surgery and chemotherapy are s trongly associated with better prognosis and multimodality treatment should be incorporated in the clinic.

Melatonin in patients with cancer receiving chemotherapy: a randomized, double-blind, placebo-controlled trial

BACKGROUND

The MIRCIT trial was a randomized, double-blind, placebo-controlled study of advanced Non-small cell lung cancer (NSCLC).

PATIENTS AND METHODS

Patients were randomized to receive 10 mg or 20 mg of melatonin or placebo. Assessment of health-related quality of life (HRQoL) was completed at baseline, and at 2, 3 and 7 months. Survival and adverse events were collected. DNA damage marker 8-oxo-7,8-dihydro-2'-deoxyguanosine (8-oxodG) was measured during the first three months of chemotherapy.

RESULTS

Patients in the melatonin-treated group had better adjusted HRQoL scores, with a slightly significantly better score (2.69 points, 95% confidence interval (CI)=0.01-5.38, p=0.049) being found in social well-being. Median survival was 7.3 months (95% CI=3.42-11.14) without significant difference. A great amont of DNA damage marker was observed in the placebo-treated group, and this was associated with lower survival (r(2)=-0.656, p=0.02), implying the protective effect of melatonin in healthy cells.

CONCLUSION

Melatonin in combination with chemotherapy did not affect survival and adverse events of advanced patients with NSCLC, but there was a trend for better HRQoL.

Effectiveness of olanzapine for the treatment of breakthrough chemotherapy induced nausea and vomiting

OBJECTIVE

To evaluate safety and efficacy of olanzapine for breakthrough emesis in addition to standard antiemetic regimen in cancer patients receiving highly emetogenic chemotherapy.

MATERIAL AND METHOD

A phase II prospective open label clinical trial was conducted in tertiary care based hospital. Forty-six cancer patients diagnosed with solid tumors were enrolled to receive at least one cycle of highly emetogenic chemotherapy (HEC) every two to four weeks. Each patient was provided standard antiemetic consisting of the generic form of ondansetron plus corticosteroids and metoclopramide according to clinical practice guideline. Olanzapine was administered as 5 mg orally every 12 hours for two doses in patients experiencing breakthrough emesis for at least one episode despite standard prevention. The efficacy and tolerability were evaluated every six hours for 24 hours (utilizing Index of Nausea, Vomiting and Retching: INVR tool).

RESULTS

Of 46 evaluable patients receiving HEC and additional olanzapine between September 2009 and July 2010, the complete response of breakthrough emesis, retching, and nausea control among patients were 60.9%, 71.7%, and 50.0%, respectively. Adverse events reported were mild and tolerable including dizziness, fatigue, and dyspepsia.

CONCLUSION

Olanzapine is considered to be safe and effective treatment of breakthrough vomiting in cancer patients undergoing highly emetogenic chemotherapy in the present study.

Adjuvant chemotherapy in resectable cholangiocarcinoma patients

BACKGROUND AND AIM

Cholangiocarcinoma patients usually have poor treatment outcome and a high mortality rate. The role of adjuvant chemotherapy (AC) is controversial. Our study aimed to evaluate benefits of AC in resectable cholangiocarcinoma patients.

METHODS

A retrospective study included 263 patients who underwent curative resection in Srinakarind University Hospital. These patients had pathological reports showing a clear margin (R0) or microscopic margin (R1) of lesion-free tissue.

RESULTS

There were 138 patients who received AC. This group had a significantly lower mean age than patients not receiving adjuvant chemotherapy (NAC) group (57.7 ± 8.5 vs 60.4 ± 9.0 years, P = 0.01). The level of serum albumin above 3 g/dL was more common in AC group than the NAC one (87.7% vs 79.2%, P = 0.04). Patients who received AC had significantly longer overall median survival time (21.6 vs 13.4 months, P = 0.01). Patients with a combination of gemcitabine and capecitabine regimen had the longest survival time (median overall survival time of gemcitabine and capecitabine 31.5, 5-fluorouracil and mitomycin 17.3, 5-fluorouracil alone 22.2, capecitabine alone 21.6, and gemcitabine alone 7.9 months, P = 0.02). Benefits of AC were likely to be found in patients who had high-risk features, that is, high level of carbohydrate antigen 19-9, advanced stage, T4 stage, lymph node involvement, and R1 margin.

CONCLUSIONS

AC significantly prolongs survival time in resectable cholangiocarcinoma patients, particularly in the high risk group.

Group versus modified individual standard-setting on multiple-choice questions with the Angoff method for fourth-year medical students in the internal medicine clerkship

BACKGROUND

The Angoff method is one of the preferred methods for setting a passing level in an exam. Normally, group meetings are required, which may be a problem for busy medical educators. Here, we compared a modified Angoff individual method to the conventional group method.

METHODS

SIX CLINICAL INSTRUCTORS WERE DIVIDED INTO TWO GROUPS MATCHED BY TEACHING EXPERIENCE: modified Angoff individual method (three persons) and conventional group method (three persons). The passing scores were set by using the Angoff theory. The groups set the scores individually and then met to determine the passing score. In the modified Angoff individual method, passing scores were judged by each instructor and the final passing score was adjusted by the concordance method and reliability index.

RESULTS

There were 94 fourth-year medical students who took the test. The mean (standard deviation) test score was 65.35 (8.38), with a median of 64 (range 46-82). The three individual instructors took 45, 60, and 60 minutes to finish the task, while the group spent 90 minutes in discussion. The final passing score in the modified Angoff individual method was 52.18 (56.75 minus 4.57) or 52 versus 51 from the standard group method. There was not much difference in numbers of failed students by either method (four versus three).

CONCLUSION

The modified Angoff individual method may be a feasible way to set a standard passing score with less time consumed and more independent rather than group work by instructors.

Prognostic factors in resectable cholangiocarcinoma patients: Carcinoembryonic antigen, lymph node, surgical margin and chemotherapy

AIM: To evaluate outcomes in resectable cholangiocarcinoma patients and to determine prognostic factors.

METHODS: A retrospective study was conducted among newly-diagnosed cholangiocarcinoma patients from January 2009 to December 2011 who underwent curative resection in Srinakarind Hospital (a 1000-bed university hospital). Two hundred and sixty-three cholangiocarcinoma patients with good performance were enrolled. These patients had pathological reports with clear margins or microscopic margins. Prognostic factors which included clinical factors, serum liver function test as well as serum tumor makers at presentation, tumor data, and receiving adjuvant chemotherapy were determined by uni- and multivariate analysis.

RESULTS: The median overall survival time was 17 mo (95%CI: 13.2-20.7); and 1-, 2-, and 3- year survival rates were 65.5%, 45.2% and 35.4%. Serum albumin levels, serum carcinoembryonic antigen (CEA) levels, staging classifications by American Joint Committee on cancer, pathological tumor staging, lymph node metastases, tumor grading, surgical margin status, and if adjuvant chemotherapy was administered, were shown to be significant prognostic factors of resectable cholangiocarcinoma by univariate analysis. Multivariate analysis, however, established that only abnormal serum CEA [hazard ratio (HR) 1.68; P = 0.027] and lymph node metastases (HR 2.27; P = 0.007) were significantly associated with a decrease in overall survival, while adjuvant chemotherapy (HR 0.71; P = 0.067) and surgical margin negative (HR 0.72; P = 0.094) tended to improve survival time.

CONCLUSION: Serum CEA and lymph node metastases which were associated with advanced stage tumors become strong negative prognostic factors in cholangiocarcinoma.

Adjuvant chemotherapy in patients with resectable cholangiocarcinoma

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Background: Cholangiocarcinoma patients usually have poor treatment outcome and high mortality rate. The role of adjuvant chemotherapy is controversy. Our study aimed to evaluate benefits of adjuvant chemotherapy in resectable cholangiocarcinoma patients. Methods: A retrospective study included 263 patients who underwent curative resection in Srinakarind university hospital. These patients had pathological report with clear margin (R0) or microscopic margin (R1). Results: There were 138 patients received adjuvant chemotherapy. This group had significantly lower mean age than patients without chemotherapy (57.7 ± 8.5 vs. 60.4 ± 9.0 years, p = 0.01). Level of serum albumin above 3g/dL was more common in adjuvant chemotherapy group than another one (87.7% vs. 79.2%, p = 0.04). Patients who received adjuvant chemotherapy had significantly longer overall median survival time (21.6 vs. 13.4 months, p = 0.01). Patients with combination of gemictabine and capecitabine regimen had the longest survival time (median overall survival time of gemcitabine and capecitabine 31.5, 5-FU and mitomycin 17.3, 5-FU alone 22.2, capecitabine alone 21.6, and gemcitabine alone 7.9 months, p = 0.02). Benefits of adjuvant chemotherapy were likely to be found in patients who had high risk features, i.e. high level of CEA, high level of CA19-9, advanced stage, T4 stage, nodal involvement and R1 margin. Conclusions: Adjuvant chemotherapy may significantly prolong survival time in resectable cholangiocarcinoma patients, particularly the high risk group.

Brain metastases from cholangiocarcinoma: a first case series in Thailand

BACKGROUND

Brain metastasis from cholangiocarcinoma (CCA) is a rare but fatal event. To the best of our knowledge, only few cases have been reported. Herein, we report the incident rate and a first case series of brain metastases from CCA.

METHODS

Between January 2006 and December 2010 5,164 patients were treated at Srinagarind hospital, Khon Kaen University; of those, 8 patients developed brain metastasis. Here we reviewed clinical data and survival times.

RESULTS

The incident rate of brain metastases from CCA was 0.15%. The median age of the patients was 60 years. Tumor subtypes were intrahepatic in 6 and hilar in 2 patients. All suffered from symptoms related to brain metastasis. Three patients were treated with whole-brain radiation therapy (WBRT), one of whom also underwent surgery. The median survival after the diagnosis of brain metastasis was 9.5 weeks (1-28 weeks). The longest survival observed in a patient in RPA class I with two brain lesions and received WBRT.

CONCLUSION

This is a first case series of brain metastases from CCA with the incident rate of 0.15%. It is rare and associated with short survival time.

Cost of colorectal cancer care in hospitalized patients of Thailand

BACKGROUND

Colorectal cancer incidence rate is high and expected to increase in Thailand. But it is a preventable and curable disease if found in the early stage of development. The overall data regarding admission rates and healthcare cost in Thai patients are lacking.

OBJECTIVE

To identify admission rates and healthcare cost of colorectal cancer.

MATERIAL AND METHOD

Information on illness of inpatients and casualties came from hospitals nationwide and from hospital withdrawals from the 3 health insurance schemes in fiscal 2010. The data included 96% of the population and were analyzed by age groups, hospital level and insurance schemes in patients with colorectal cancer.

RESULTS

Colorectal cancer occurred in 45,692 of all admissions, contributing to admission rates of 98.5 per 100,000 persons. These figures increased with age. The highest admission was found in the central region including Bangkok (43%) followed by the northeast region (23%). The average hospital charges per admission in three insurance schemes groups: government welfare, social welfare and universal coverage were 64,241, 49,490 and 28,588 Baht, respectively

CONCLUSION

Admission rates showed that colorectal cancer increased with age. The highest rate was observed in sixty years and older The hospital charges were extensive, especially in those on the government welfare scheme. Thus, screening programs, cost-effective analysis of treatment modalities and treatment protocol for the elderly should be examined.

Patterns of chemotherapy usage in hospitalized breast cancer patients

BACKGROUND

Breast cancer is the leading cancer in Thai women. Systemic chemotherapy is one of the main treatment options in both adjuvant and metastatic disease. Patterns of chemotherapy usage and hospital cost data are lacking.

OBJECTIVE

To identify overall admission rate, chemotherapy admission and hospital cost data of breast cancer patients.

MATERIAL AND METHOD

Information on illness of inpatients and casualties came from hospitals nationwide and from hospital withdrawals from the three health insurance schemes in the fiscal 2010. The data included 96% of the population. The data were analyzed by age groups, regions, hospital levels and insurance schemes in breast cancer patients.

RESULTS

Admissions from breast cancer occurred for 35,490 in the year 2010. Admissions for systemic chemotherapy accounted for 53.1% of all breast cancer admissions and accounted for 17.3% of all admissions for chemotherapy. Most of chemotherapy admissions were in tertiary care hospital level. Mean length of stay for chemotherapy in breast cancer was 2.33 days compared to 5.30 days in other cancers. Mean hospital charge for chemotherapy for breast cancer was 13,904 THB compared to 33,693 THB for other cancers. The mean hospital charge three insurance schemes groups: government welfare, social welfare and universal coverage were 33,096, 19,932 and 9,599 THB, respectively.

CONCLUSION

Admission rate for chemotherapy in breast cancer was not high. The cost of chemotherapy in each admission in breast cancer is nearly 50% lesser than chemotherapy for other cancers. Thus, generic drugs usage and outpatient administration of chemotherapy should be encouraged.

Lung cancer in hospitalized patients of Thailand

OBJECTIVE

To identify admission rates, treatments and healthcare cost of lung cancer

MATERIAL AND METHOD

Information on illness of inpatients and casualties came from hospitals nationwide and from hospital withdrawals from the 3 health insurance schemes in the fiscal year 2010. The data included 96% of the population and were analyzed by age groups, hospital levels, treatment and insurance schemes in patients with lung cancer.

RESULTS

Lung cancer occurred in 27,896 of all admissions, contributing to admission rate of 60 per 100,000 persons. The admission rates were markedly increased in male more than 60 years old. The majority of treatments were palliative care 61.38%, chemotherapy 36.81%. The average length of stay and hospital charges in three insurance schemes groups: government welfare, social welfare and universal coverage were 40,571.29 Baht/9.86 days, 43,342.54 Baht/8.24 days and 17,897.75 Baht/6.08 days, respectively.

CONCLUSION

Admission rates showed that lung cancer increased with age. The highest rate was observed in more than 60 years old. The window gap in hospital charges and length of stay in three insurance schemes are interesting. Thus, analysis of treatment protocol should be examined.

Systemic therapy for locally advanced and metastatic cholangiocarcinoma

Cholangiocarcinoma, the typical bile duct epithelium neoplasm, is most commonly reported in the Northeast of Thailand. Surgical intervention is the only possible curative treatment in the early stage of disease. Unfortunately, most patients are advanced at the time of diagnosis and not appropriate for curative surgical treatment. The prognosis of advanced CCA is extremely poor and chemotherapy is the only approved treatment for this stage of disease. This article reviews the state-of-art chemotherapy for locally advanced or metastatic cholangiocarcinoma.

Evaluation of efficacy, safety and tolerability of high dose-intermittent calcitriol supplementation to advanced intrahepatic cholangiocarcinoma patients--a pilot study

Antitumor activity (growth suppression) of vitamin D has been demonstrated using cholangiocarcinoma (CCA) cell lines, CCA cell-grafted animal models, and human CCA tissue cultures. The present study aimed to determine the toxicity and tolerability of intermittent-high dose calcitriol in advanced inoperable intrahepatic CCA patients and to evaluate the therapeutic efficacy of combinations of calcitriol and 5-fluorouracil-based chemotherapeutic drugs. The patients were divided into 3 groups: the first (n=2) received intermittent-high dose oral calcitriol 12 μg/day for 3 days, i.e. Monday-Wednesday, per week up to 3 months. The treatment did not cause any serious adverse events, except hypercalcemia grade I, once in 72 administrations. The second group (n=3) received chemotherapeutic drugs (5-fluorouracil, Mitomycin C and Leucovorin) for 3 cycles, one patient showing a partial response. The third group (n=4) received high dose calcitriol in combination with chemotherapeutic-drugs. All 4 patients encountered serious adverse events and two of them were withdrawn after the first drug cycle. This pilot study suggests that, although high dose-intermittent calcitriol appeared to be safe and tolerated well in advanced intrahepatic CCA patients, co-administration with 5-fluorouracil-based chemotherapeutic drugs caused unexpected potentiation of their toxicity. Adjustment of the doses of both drugs is required to avoid such toxicity and to optimize therapeutic efficacy of anticancer drugs when they were combined with high dose-intermittent calcitriol.

Prevalence and management of cancer pain in Srinagarind Hospital, Khon Kaen, Thailand

OBJECTIVE

Cancer pain remains an invisible problem in cancer care and our study aimed to document its prevalence, characteristics, and patterns of management at a tertiary care teaching hospital.

STUDY DESIGN

Descriptive, prospective, cohort study.

MATERIAL AND METHOD

We recruited 335 consecutive adult patients diagnosed with cancers, admitted to Srinagarind Hospital, between February and April 2004. All of the participants were interviewed, and their pain evaluated by direct assessment using a numeric rating scale.

RESULTS

The overall prevalence of cancer pain prior to admission was 56.5%, and within the first 24 hours of admission 41.5%. Three-quarters (74%) of patients with pain reported improvement; however one-third of those with pain never received any pain control intervention. Moreover; about half of those with persistent pain only received treatment by requesting it and then only received simple analgesics.

CONCLUSION

Cancer pain remains under-detected and under-treated in many patients. Pain monitoring on a regular basis as well as a training program on pain management should be considered as first-line tools for improving pain control among cancer patients.