One-stage versus two-stage Roux-Y gastric bypass as redo surgery of failed adjustable gastric banding

INTRODUCTION

The study focussed on whether a one-stage Roux-Y gastric bypass (OS-RYGB) or a two-stage RYGB (TS-RYGB) has a significant advantage in terms of perioperative risk in patients after failed adjustable gastric banding (AGB).

METHODS

Data collection included patients who underwent OS-RYGB or TS-RYGB after AGB between 2005 and 2019 and whose outcomes were compared with those after primary RYGB (P-RYGB). Outcome criteria were perioperative complications, comorbidities, 30-day mortality and operating time.

RESULTS

The study analysed data from patients who underwent OS-RYGB (N = 525), TS-RYGB (N = 382) and P-RYGB (N = 26,445). Intraoperative and postoperative complication rates were significantly lower for P-RYGB (p < 0.001). Total intraoperative and specific postoperative complication rates were significantly lower in TS-RYGB than in OS-RYGB (p = 0.048 and p < 0.001, respectively). In contrast, the total general postoperative complication rate was lower in OS-RYGB than in TS-RYGB (p < 0.001). The mean operating time differed significantly among the three groups (P-RYGB 96.5min, OS-RYGB 141.2min and TS-RYGB 190.9min; p < 0.001). The mortality rate was not significantly different between the three groups.

CONCLUSIONS

Based on the significant difference between the two groups in revision surgery and the slight difference with the results of primary RYGB, this study concludes that removal of a failed AGB is safe and feasible with either the OS- or TS-RYGB procedure. However, we cannot directly recommend either procedure in our study. Proper patient selection and surgeon experience are critical to avoid potential adverse effects.

Ythdf2 regulates cardiac remodeling through its mRNA target transcripts

m6A mRNA methylation controls cardiomyocyte function and increased overall m6A levels are a stereotyping finding in heart failure independent of the underlying etiology. However, it is largely unknown how the information is read by m6A reader proteins in heart failure. Here we show that the m6A reader protein Ythdf2 controls cardiac function and identified a novel mechanism how reader proteins control gene expression and cardiac function. Deletion of Ythdf2 in cardiomyocytes in vivo leads to mild cardiac hypertrophy, reduced heart function, and increased fibrosis during pressure overload as well as during aging. Similarly, in vitro the knockdown of Ythdf2 results in cardiomyocyte growth and remodeling. Mechanistically, we identified the eucaryotic elongation factor 2 as post-transcriptionally regulated by Ythdf2 using cell type specific Ribo-seq data. Our study expands our understanding on the regulatory functions of m6A methylation in cardiomyocytes and how cardiac function is controlled by the m6A reader protein Ythdf2.

Translational control of Ybx1 expression regulates cardiac function in response to pressure overload in vivo

RNA-protein interactions are central to cardiac function, but how activity of individual RNA-binding protein is regulated through signaling cascades in cardiomyocytes during heart failure development is largely unknown. The mechanistic target of rapamycin kinase is a central signaling hub that controls mRNA translation in cardiomyocytes; however, a direct link between mTOR signaling and RNA-binding proteins in the heart has not been established. Integrative transcriptome and translatome analysis revealed mTOR dependent translational upregulation of the RNA binding protein Ybx1 during early pathological remodeling independent of mRNA levels. Ybx1 is necessary for pathological cardiomyocyte growth by regulating protein synthesis. To identify the molecular mechanisms how Ybx1 regulates cellular growth and protein synthesis, we identified mRNAs bound to Ybx1. We discovered that eucaryotic elongation factor 2 (Eef2) mRNA is bound to Ybx1, and its translation is upregulated during cardiac hypertrophy dependent on Ybx1 expression. Eef2 itself is sufficient to drive pathological growth by increasing global protein translation. Finally, Ybx1 depletion in vivo preserved heart function during pathological cardiac hypertrophy. Thus, activation of mTORC1 links pathological signaling cascades to altered gene expression regulation by activation of Ybx1 which in turn promotes translation through increased expression of Eef2.

P10.20.A Mechanisms of synergistic glioma growth suppression by radiotherapy and MET inhibition

Background

Glioblastoma remains to be one of the most lethal solid cancers. Despite multi-modal therapy including surgery as safely feasible, radiotherapy and chemotherapy with the alkylating agent temozolomide, the median survival of affected patients is still limited to approximately one year on a population level. Thus, novel therapies are urgently needed. There is increasing interest in the role of the HGF/MET pathway in the response of glioblastoma to radiotherapy since MET may be involved in radioresistance via proinvasive and DNA damage response pathways.

Material and Methods

Here we assessed the role of the MET pathway in the response to radiotherapy in vitro and in vivo in syngeneic mouse glioma models and explored potential modes of action responsible for the synergistic effects of MET pathway inhibition and irradiation on tumor growth in vivo.

Results

Murine glioma cells express HGF and MET and show increased MET phosphorylation upon exposure to exogenous HGF. In vitro, glioma cell viability and proliferation are not affected by pharmacological MET inhibition using tepotinib or genetic MET inhibition using CRISPR/Cas9-engineered Met gene knockout and sensitization to irradiation by MET inhibition is not seen. In vivo, the combination of MET inhibition with focal radiotherapy mediates prolonged survival of syngeneic orthotopic glioma-bearing mice compared with either treatment alone. Complementary studies demonstrate that synergy is lost when gliomas are established and treated in immunodeficient mice, but also if MET gene expression is disrupted in the tumor of wildtype mice. Combination therapy suppresses a set of pro-inflammatory mediators that are upregulated by radiotherapy alone and which are positively regulated by transforming growth factor (TGF)-β. In line with this data, ex vivo analysis of mouse brains reveal increased TGF-β pathway activity upon irradiation alone that is counteracted by concomitant MET inhibition.

Conclusion

In summary, we demonstrate synergistic suppression of syngeneic glioma growth by irradiation and MET inhibition that requires MET expression in the tumor as well as an intact immune system. Clinical evaluation of this combined treatment approach in newly diagnosed glioblastoma is warranted.

Muscle-specific Cand2 is translationally upregulated by mTORC1 and promotes adverse cardiac remodeling

The mechanistic target of rapamycin (mTOR) promotes pathological remodeling in the heart by activating ribosomal biogenesis and mRNA translation. Inhibition of mTOR in cardiomyocytes is protective; however, a detailed role of mTOR in translational regulation of specific mRNA networks in the diseased heart is unknown. We performed cardiomyocyte genome-wide sequencing to define mTOR-dependent gene expression control at the level of mRNA translation. We identify the muscle-specific protein Cullin-associated NEDD8-dissociated protein 2 (Cand2) as a translationally upregulated gene, dependent on the activity of mTOR. Deletion of Cand2 protects the myocardium against pathological remodeling. Mechanistically, we show that Cand2 links mTOR signaling to pathological cell growth by increasing Grk5 protein expression. Our data suggest that cell-type-specific targeting of mTOR might have therapeutic value against pathological cardiac remodeling.

Perceived Barriers in the Decision for Bariatric and Metabolic Surgery: Results from a Representative Study in Germany

BACKGROUND

Attitudes of the general public may be an influencing factor for low surgery rates: When skepticism is high, support for individuals wanting or needing to undergo surgery may diminish. This study assesses the relevance of barriers to metabolic surgery.

METHODS

The study was conducted using a representative sample of the German population (n = 1007). Participants were asked to imagine that they would have to decide for or against metabolic surgery and rate how this decision would be influenced by a number of reasons given to them (Likert scale). Results are presented by weight status.

RESULTS

The barrier found most irrelevant is that surgery could be considered cheating across all weight groups. About a fourth of the sample state that not knowing enough about surgery (28.5%), being afraid of surgery (28.3%), and potential negative consequences after surgery (24.5%) are reasons against metabolic surgery that were rated extremely relevant. Having obesity was a significant predictor of endorsement in two variables: feeling like cheating (lower probability for relevance, OR = 0.58, p = 0.025) and a lack of knowledge (lower probability for relevance, OR = 0.59, p = 0.031).

CONCLUSIONS

In summary, the public's view of weight loss surgery lacks information about post-surgical consequences. It is important to address these points in the public and in social networks of patients as they may be pre- or antecedent of surgery stigma.

[Referral behavior of general physicians for patients with obesity]

The prevalence of obesity and overweight is constantly rising. Thus, obesity is increasingly considered as one of the most important healthcare problems in Germany. Surgical interventions have been proven to be the only treatment option to achieve sustained weight loss along with a reduction of obesity-related comorbidities in the vast majority of morbidly obese patients. With respect to the small numbers of weight loss surgeries conducted in Germany, several reasons are currently discussed. General practitioners play a very important role in gatekeeping when it comes to decisions about treatment. Research has shown that knowledge and stigma play a role when treatment pathways for patients with obesity are defined. Interventions are required to make treatment decisions by physicians or patients independent of social pressure due to stigma or gaps in expertise.

[Revisional surgery and reoperations in obesity and metabolic surgery : Data analysis of the German bariatric surgery registry 2005-2012]

BACKGROUND

Increasing numbers of interventions for obesity and metabolic surgery have led to an increase of primary bariatric operations as well as redo operations and revisional surgery after various primary bariatric procedures. Evidence-based guidelines for indications and choice of procedure for revisional surgery do not currently exist.

AIM

The spectrum of various revisional and redo operations following standard operative procedures for obesity and metabolic surgery is presented based on current data from the German bariatric surgery registry (GBSR, German nationwide survey on quality assurance in bariatric surgery) and a literature search.

MATERIAL AND METHODS

Since 1 January 2005, the current situation of bariatric surgery has been examined using the GBSR. All data are registered prospectively in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University Magdeburg. Since 2005 a total of 24,070 primary bariatric procedures, 2070 revisional procedures and 1124 redo operations were analyzed. The study evaluated 1021 revisional and 491 redo operations after gastric banding (GB), 443 redo operations after sleeve gastrectomy (SG) and 306 revisional procedures and 10 redo operations after a Roux-en-Y gastric bypass (RYGBP).

RESULTS

Reoperations of GB to SG were performed in 240 cases. The complication rate for GB removal and SG showed a significantly higher leakage rate for one step operations than for two step procedures of 3.3% vs. 0.0%. Conversion of GB to RYGBP was performed in 402 operations without any significant differences between one and two step approaches (1.9% vs. 2.2%). The specific complication rate in the 443 interventions in patients for conversion from SG to RYGBP was 10.8% which is higher than for primary SG (4.9%) and RYGBP (5.3%).

CONCLUSION

Compared with the primary surgical procedures redo operations and revisional procedures have significantly higher complication rates. The data evaluated show that strong and differentiated indications are necessary for revisional and redo operations particularly in cases of therapy or metabolic failure.

[Comment on Gender-Specific Aspects in Obesity and Metabolic Surgery--Analysis of Data from the German Bariatric Surgery Registry]

BACKGROUND

The current situation in obesity and metabolic surgery since January 2005 has been investigated with the help of the quality assurance study on surgical therapy for obesity = German Bariatric Surgery Registry (GBSR). The data were acquired and analysed in cooperation with the Institute for Quality Assurance in Surgical Medicine at the Otto-von-Guericke University.

METHODS

Data acquisition was done with the help of an online database. On a voluntary basis, all obesity and metabolic surgical interventions since 2005 have been recorded. In addition to the surgical data, the findings of the yearly follow-up investigations were recorded.

RESULTS

Since 2005 there have been 1,263 gastric balloon procedures, 11,840 sleeve gastrectomies, 13,722 Roux-en-Y gastric bypasses and 3999 gastric banding operations. The average age of the male patients in all interventions was significantly higher. The average BMI of female patients who received a gastric banding or a gastric balloon procedure was significantly lower than that of the male patients. Men exhibited a higher incidence of comorbidities than women.

CONCLUSION

The number of obesity and metabolic surgical interventions in Germany is continuously increasing. The results of the study on surgical therapy for obesity (GBSR) reveal significant differences in the gender-specific incidence of preoperative comorbidities. postoperative complications and mortality. Further studies on gender-specific aspects are necessary in order to optimise patient selection and reduce the incidence of postoperative complications.

[Management of complications in bariatric surgery]

Bariatric surgery is known to be the most effective and long-lasting treatment for morbid obesity and associated comorbidities. These comorbidities together with cardiopulmonary decompensation make morbidly obese patients a high risk group for operative interventions. Early detection of postoperative complications is a challenging task in these patients and requires accurate and timely interpretation of any alarm signals. Symptoms, such as tachycardia and abdominal pain are highly suspicious. The same applies to elevated inflammatory parameters and fever. Early diagnostic laparoscopy is mandatory once cardiopulmonary complications have been excluded. Moreover, it has a higher sensitivity and specificity than other radiological modalities and is a minimally invasive procedure with a highly satisfactory outcome.

[Is there a role for surgery in the treatment of type 2 diabetes?]

Typ 2 diabetes mellitus (T2DM) can be regarded as a chronic and progressive disease which is rapidly increasing worldwide. There is a significant coincidence of T2DM and obesity, the latter playing a major role in the development of insulin resistance. Medical treatment comprises lifestyle counseling, weight management and an increased physical activity, frequently in combination with pharmacotherapy. However, especially in obese patients, metabolic aims are frequently not achieved which can be attributed to the lack of significant weight reduction. Currently, pancreas transplantation plays only a minor role in the treatment of patients with T2DM. Bariatric surgery has been proven to be a safe and effective therapeutic option in obese patients that leads to a significant weight loss. Moreover, in the majority of obese diabetics, a complete or partial remission of T2DM is observed. The significant weight loss is associated with improved insulin sensitivity. There is some evidence that alterations of gut hormones play an additional role in the amelioration of T2DM. However, little is known about the long-term effect of bariatric surgery on diabetes remission. Bariatric procedures should be considered in obese patients with T2DM (BMI > 35 kg/m²) and poorly controlled metabolic status. Despite the encouraging results in normal weight or overweight patients with T2DM, surgery can not yet be recommended in these patients. Intensive research about the impact of bariatric surgery on diabetes remission offers a unique opportunity to understand pathophysiology of T2DM. Furthermore, it may help to develop less invasive interventions and to identify new therapeutic targets for the treatment of T2DM.

[Current Situation of Antibiotic Prophylaxis in Obesity and Metabolic Surgery - Data Analysis from the Study for Quality Assurance in Operative Treatment of Obesity in Germany]

BACKGROUND

Since January 2005, the situation of metabolic and obesity surgery in Germany has been constantly evaluated by the German Bariatric Surgery Registry (GBSR). Data registration is performed using an internet online database with prospective data collection. All registered data were analysed in cooperation with the Institute of Quality Assurance at the Otto-von-Guericke University Magdeburg.

METHODS

Data collection includes primary and revision/redo-procedures. A main focus of the current study is the analysis of data regarding the perioperative management, in particular, administration of antibiotics.

RESULTS

Since 2005 a significant increase of primary bariatric procedures has been reported. For evaluation of the antibiotic regimen 12 296 primary operations including 684 balloons (BIB), 2950 gastric bandings (GB), 5115 Roux-en-Y-gastric bypasses (RYGBP), 120 Scopinaro's biliopancreatic diversions (BPD), 164 duodenal switches (DS), 3125 sleeve gastrectomies (SG) and 138 other procedures were analysed. In total 77.3 % of the patients with primary procedures received perioperative antibiotics. Patients without concomitant comorbidities received antibiotics significantly less often compared to those with comorbidities. Wound infection rates were comparable for patients who underwent either gastric banding or sleeve gastrectomy.

CONCLUSION

Surgery has been accepted step by step as a treatment for morbid obesity and its comorbidities in Germany during the last few years. There is only little experience in the literature regarding antibiotic therapy as well as prophylaxis in bariatric surgery. Based on the results of the current study we recommend rather the selective than the routine use of antibiotics depending on different parameters, e.g., operative time, preoperative BMI and concomitant comorbidities.

[Increased requirements for the challenging abdominosurgical management of morbid obesity - what does the abdominal surgeon need to know?]

In the international comparison and in Europe, the Federal Republic of Germany belongs to the countries with a very high prevalence of obesity (men, 67.1 %; women, 53 %). Among the European countries, the incidence of diabetes mellitus type 2 is also high ("Study of the health of adults in Germany" [DEGS]) - Robert Koch Institute). Not only for surgeons, this can be considered as a great challenge even in usual abdominosurgical interventions. 1. Surgical equipment needs to be adapted to the requirements for obese patients. 2. Minimally invasive surgery reduces not only complication rates with regard to postsurgical wound infection and hernia in such patients, it allows a competent assessment of the peritoneal cavity. 3. A great number of surgical tools and instruments can be used in normal weight as well as morbidly obese patients with no limitations - for conventional (open) surgical interventions, retractor systems should be available. 4. With regard to emergency surgery in patients who had formerly undergone bariatric surgery, a competent basic knowledge on the usual bariatric surgical interventions and the subsequent anatomic consequences as well as the more frequent mid- and long-term complications is necessary, which need to be partially approached with the surgical intervention. 5. For numerous oncosurgical interventions, no differences in postoperative outcome were found between normal weight and morbidly obese patients.

[Nutrient Deficiencies after Bariatric Surgery - Systematic Literature Review and Suggestions for Diagnostics and Treatment]

The increasing prevalence of morbid obesity in Germany is associated with an increasing number of metabolic surgical interventions. Short-term surgical and long-term metabolic complications such as nutrient deficiencies can be considered the main risks of metabolic surgery and its restrictive and malabsorbant surgical procedures. The aim of this compact short overview based on a selective literature search and our own clinical experience is to characterise the long-term metabolic complications, which are specific for the various bariatric procedures, and to refine the published guidelines for supplementation. Restrictive bariatric procedures can be associated with well-known surgical problems such as pouch dilatation or band migration, e.g., after gastric banding. After sleeve gastrectomy, emerging reflux disease can become a substantial problem. The most frequent deficiencies after restrictive procedures are related to B-vitamins whereas iron, folate, vitamin B1 and B12 and vitamin D deficiencies are associated with the malabsorptive procedure such as biliopancreatic diversion, duodenal switch and Roux-en-Y gastric bypass. Due to possible metabolic and surgical complications after bariatric surgery, patients need to undergo life-long medical follow-up investigations. The currently available guidelines of German Society of Treatment of Obesity (CAADIP) of DGAV for supplementation should be known and followed, in particular, by the physicians who i) are exceptionally involved in medical care of obese people and ii) do it in full awareness of the obligatory postoperative clinical observation.

[New data on quality assurance in bariatric surgery in Germany]

BACKGROUND

Since January 1st 2005, the situation of bariatric surgery has been examined in Germany. All data are registered prospectively in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University of Magdeburg.

METHODS

The voluntary data registration occurs in an internet online data bank. All primary bariatric procedures as well as re- and redo-procedures are documented. Follow-up data were collected once a year. Participation in the quality assurance study is obligatory for certificated centres.

RESULTS

Since 2005 13,879 bariatric procedures have been performed at 83 hospitals. The number of primary procedures has increased from 596 in 2005 to 11,835 in 2010. Revisional surgery has been performed in 1,438 patients since 2005. Sleeve gastrectomy (SG) is the major procedure with 1,564 operations in 2010. The mean BMI was 48.8 kg/m². The incidence of comorbidities was 84.8%.

CONCLUSION

Bariatric surgery has become more accepted in Germany. Beside the Roux-en-Y gastric bypass, sleeve gastrectomy is the most frequently performed operation. BMI and incidence of comorbidities are still high in comparison with literature values. Due to the lack of evidence, more randomised studies are necessary to standardise operative techniques and evaluate patient selection criteria. Quality assurance studies support a detailed analysis of these parameters.

Evaluation of EGFR gene copy number as a predictive biomarker for the efficacy of cetuximab in combination with chemotherapy in the first-line treatment of recurrent and/or metastatic squamous cell carcinoma of the head and neck: EXTREME study

Background: The phase III EXTREME study demonstrated that combining cetuximab with platinum/5-fluorouracil (5-FU) significantly improved overall survival in the first-line treatment of patients with recurrent and/or metastatic squamous cell carcinoma of the head and neck (R/M SCCHN) compared with platinum/5-FU alone. The aim of this investigation was to evaluate elevated tumor EGFR gene copy number as a predictive biomarker in EXTREME study patients.

Patients and methods: Dual-color FISH was used to determine absolute and relative EGFR copy number. Models of differing stringencies were used to score and investigate whether increased copy number was predictive for the activity of cetuximab plus platinum/5-FU.

Results: Tumors from 312 of 442 patients (71%) were evaluable by FISH and met the criteria for statistical analysis. A moderate increase in EGFR copy number was common, with high-level amplification of the gene occurring in a small fraction of tumors (∼11%). Considering each of the models tested, no association of EGFR copy number with overall survival, progression-free survival or best overall response was found for patients treated with cetuximab plus platinum/5-FU.

Conclusion: Tumor EGFR copy number is not a predictive biomarker for the efficacy of cetuximab plus platinum/5-FU as first-line therapy for patients with R/M SCCHN.

[Bariatric surgery in children and adolescents]

Obesity in childhood and adolescents has gained epidemic proportions; in Germany 15-20 % of boys and girls are overweight, more than 6 % are known to be obese. By now, 25 % of relevant people show a pathological glucose intolerance, 4-5 % are developing type 2 diabetes mellitus (T2DM). In addition, metabolic disorders leading to hypertension and cardiac, renal or ophthalmological complications could be named as serious comorbidities. Medical and behavioural intervention as treatment for obesity in childhood remains largely ineffective: 5-10 % weight loss within 2 years rarely results in significant durable success. In adults, bariatric surgery is being used increasingly as an effective approach to achieve weight loss and to improve serious medical comorbidities, in particular T2DM. Enhancement of quality of life and explicit extension of survival are concomitant phenomenons. To date, a range of different types of bariatric procedures has been performed in adolescents, but studies evaluating and analysing preoperative data, postoperative course and follow-up in a representative number of patients younger than 18 years are still lacking. Nevertheless, current experience suggests significant weight loss and improving obesity-related medical comorbidities after bariatric surgery in adolescents too. Moreover, bariatric surgery in adolescents seems to induce less complications and a shorter hospital stay than in adults. Al-though surgical therapy for obesity in this group of patients remains an individual decision, even though explicit guidelines have been published specifying inclusion and exclusion criterias. Analysis of our own patient group and results of the study of the quality assurance "surgical treatment of morbid obesity" are appropriate tools to evaluate surgical techniques and to provide long-term follow-up.

Predictive biomarkers to improve treatment of metastatic colorectal cancer (mCRC): Outcomes with cetuximab plus FOLFIRI in the CRYSTAL trial

4068

Background: KRAS oncogene mutation status is predictive of efficacy of cetuximab alone or combined with chemotherapy (CT) in mCRC. Previous data from the phase III CRYSTAL trial showed that adding cetuximab to FOLFIRI in first-line mCRC significantly improved the overall response rate (ORR) and progression-free survival (PFS) in pts with KRAS wild-type (wt) tumors. The serine-threonine kinase BRAF is a direct downstream effector of KRAS. Here, we report the influence of KRAS and BRAF status on mature overall survival (OS) data. Methods: DNA was extracted from archived tumor material where available from randomized pts. KRAS and BRAF mutation status (wt or mutant [mt]) was determined by quantitative PCR. Treatment arms were compared using two-sided log-rank tests (5% significance level) for PFS and OS, and the CMH test for best ORR. Results: The KRAS-evaluable cohort (n=540; 64.4% KRAS wt) was similar to the overall ITT group. In KRAS wt pts, adding cetuximab to FOLFIRI significantly increased the odds for tumor response nearly 2-fold, reduced the risk of progression by 32% and extended median OS from 21.0 months (mo) to 24.9 mo (details in Table ). KRAS mt pts did not benefit from cetuximab. Data on the impact of BRAF mutations on cetuximab activity will be presented at the meeting. In the FOLFIRI and cetuximab + FOLFIRI arms, 31.2% and 36.1% of pts, respectively, received no further line of therapy, while 25.4% and 6.2%, respectively, received EGFR antibody therapy. Conclusions: The benefits of adding cetuximab to CT were greater in KRAS wt pts than ITT pts for all clinically relevant endpoints. KRAS is a key biomarker for selecting a targeted therapy combined with standard CT in first-line mCRC.

[Table: see text]

[Table: see text]

Biomarker potential of EGFR gene copy number by FISH in the phase III EXTREME study: Platinum-based CT plus cetuximab in first-line R/M SCCHN

6005

Background: Platinum-based CT + cetuximab is the first systemic therapy in ∼30 years to show a survival benefit vs platinum-based CT in first-line R/M SCCHN (Vermorken JB, et al. N Engl J Med 2008;359:1116–1127). A retrospective analysis has evaluated the influence of EGFR gene copy number, determined by FISH, on clinical outcome in the EXTREME study. Methods: Pts were randomized to 3-weekly cycles of platinum-based CT (cisplatin 100 mg/m2 or carboplatin AUC 5, day 1; 5-fluorouracil 1000 mg/m2/day continuous infusion, days 1–4) with or without cetuximab (initial dose 400 mg/m2, then 250 mg/m2 weekly). The proportion of FISH+ cells per pt (FISH score) was determined using 5 different enrichment models. Tumors were also classified as FISH+ or FISH- using the Colorado scoring system. Results: In the overall population (n=442), addition of cetuximab significantly improved median OS (10.1 vs 7.4 months; p=0.04). No association between FISH score and OS, PFS, or best overall response was determined for any enrichment model. Pts with Colorado FISH+ tumors were evenly distributed between the CT + cetuximab (50/158) and CT-alone (51/154) arms of the FISH- evaluable population (71% of ITT population). Colorado FISH status had no influence on OS in either treatment arm, on PFS in the CT-alone arm, or on RR in the CT + cetuximab arm (see table ). In the CT + cetuximab arm, pts with FISH+ tumors had a lower risk of progression than pts with FISH- tumors. Higher RRs among pts with FISH- tumors in the CT-alone arm may have been due to twice as many nonevaluable response observations in the FISH+ vs the FISH- population (percentage of pts with SD or PD was comparable). Conclusions: EGFR gene copy number, as determined by FISH, is not a predictive biomarker for cetuximab efficacy in R/M SCCHN.

[Table: see text]

[Table: see text]

Molecular and clinical predictors of outcome for cetuximab in non-small cell lung cancer (NSCLC): Data from the FLEX study

8007

Background: The multinational, randomized, phase III FLEX study compared cisplatin/vinorelbine (CT) plus the EGFR- antibody, cetuximab (Erbitux), with CT alone in the 1st-line treatment of patients (pts) with advanced EGFR-expressing NSCLC and demonstrated a statistically significant OS benefit for the cetuximab combination. We hypothesized that KRAS mutation status is predictive for cetuximab efficacy and enables optimal use of cetuximab. The relationship between early-onset acne-like rash (ie rash that developed ≤21 days of treatment initiation) and OS time of pts treated with CT and cetuximab was also evaluated. Methods: Archived tumor samples from 554/1125 pts were available. Genomic DNA derived from formalin-fixed paraffin embedded tumor tissue was analyzed for KRAS using an LNA-mediated qPCR clamping assay capable of detecting oncogenic mutations at codons 12 and 13. The Kaplan-Meier method was used to estimate OS time and PFS time in pts with KRAS wild-type (wt) and mutant (mt) tumors for each treatment arm. All pts treated with cisplatin/vinorelbine plus cetuximab who were alive at 21 days were included in a landmark analysis evaluating the relationship between early-onset acne-like rash and OS time. Results: KRAS results were obtained from 379 pts. A KRAS mutation was detected in 72 (19%) pts. The comparison of the cetuximab treatment effects in pts with KRAS wt tumors and pts with KRAS mt tumors showed no marked differences with regard to OS or PFS. A total of 518 pts were included in the landmark analysis. Pts treated with cetuximab who developed early acne-like rash of any grade (grade 1–3; 56%, n=290) had a longer median OS than those without acne-like rash (n=228) (median [95% CI]: 15.0 months [12.8–16.4] vs 8.8 months [7.6–11.1]; HR [95% CI]: 0.63 [0.52–0.77]; p<0.001). Analysis of EGFR FISH is ongoing and results will be presented. Conclusions: Clinical data from the FLEX study do not support the hypothesis that KRAS mutation status is predictive for cetuximab efficacy when combined with 1st- line chemotherapy in advanced NSCLC, whereas early acne-like rash of any grade appears to be associated with better outcome in pts treated with platinum-based chemotherapy plus cetuximab in this setting.

[Table: see text]

[PCO syndrome--is it an indication for bariatric surgery?]

BACKGROUND

The polycystic ovary syndrome (PCOS) is the most frequent cause of female infertility with an estimated prevalence of 6-10% in premenopausal women. Due to its long-term metabolic and cardiovascular consequences, it poses a severe health problem. Visceral obesity and subsequent insulin resistance represent the core pathophysiology of PCOS, clearly suggesting that measures to reduce abdominal obesity should be pursued.

METHODS

Between February 1995 and October 2006, 204 patients underwent bariatric surgery in the SRH Hospital of Gera. 75% of the patients were female and three of them were suffering preoperatively from polycystic ovary syndrome and metabolic syndrome.

RESULTS

104 months after laparoscopic adjustable gastric banding, the excess body weight loss (EBWL) was 49, 67 and 41% in these three patients, respectively. Glucose levels normalised completely. One patient became pregnant after weight reduction.

CONCLUSIONS

In PCOS with metabolic syndrome, bariatric surgery is an option to reduce weight and to treat associated metabolic disorders. Surgery should be performed based on the body mass index, the metabolic disorders, and the wish of the patient to become pregnant.

[Quality assurance in bariatric surgery in Germany--results of the German multicentre trial 2005 and 2006]

BACKGROUND

Since January 1st 2005, the situation of bariatric surgery in Germany has been examined. The data are registered in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke-University Magdeburg.

METHODS

The data registration took place prospectively in an internet online data base. All primary bariatric procedures performed since January 1st 2005 were detected as well as re-operations in patients who had been operated before.

RESULTS

629 patients underwent bariatric surgery in 21 hospitals in 2005 and 828 patients were operated in 32 hospitals in 2006. The mostly performed operation was gastric banding with 46.8 %, followed by Roux-Y gastric bypass with 38.5 %. 74.4 % of the patients were female. The medium BMI of all patients was 48.5 kg/m2 in 2005 and 48.4 kg/m2 in 2006. Follow-up data were available for 71.2 % of the patients operated in 2005. These data show a higher reduction of BMI after malabsorptive than after restrictive bariatric procedures.

CONCLUSION

A trend from restrictive bariatric procedures to a malabsorptive approach could be observed. In Germany the BMI of patients undergoing bariatric surgery is higher than in most countries world-wide. No differences could be detected in intraoperative and short-term complications as well in the complication rate in the first year of follow-up in comparison with the literature.

Experiences of two centers of bariatric surgery in the treatment of intragastrale band migration after gastric banding-the importance of the German multicenter observational study for quality assurance in obesity surgery 2005 and 2006

BACKGROUND

Adjustable silicone gastric banding (ASGB) is an effective treatment in morbid obesity. Band migration is a long-term complication. Causes, clinical symptoms, timing and incidence are investigated in single centres only. In Germany, since January 1st, 2005, practice in bariatric surgery has been investigated in German prospective multicenter trial for quality assurance in obesity surgery.

MATERIALS AND METHODS

All patients underwent ASGB in two centres of bariatric surgery in Germany were prospectively registered using a computer-based data form. Patients with band migration were retrospectively evaluated, in particular, causes and characteristics of its management. The results were correlated with data obtained from the German prospective multicentre trial.

RESULTS

In total, 493 patients were enrolled in the study from February 1995 to February 2007. The follow-up rate was 79.9% (mean follow-up time period, 78.7 months; range, 2-148 months). Fifteen patients (3.0%) developed migration. In 14 cases, migration occurred within the range of 30-86 months after implantation. In one case, migration occurred 10 months after repositioning of the band. In the German multicentre trial, 629 patients underwent surgery during 2005 and 827 patients in 2006. In both periods, 74.4% of the patients were female and 25.6% male. The most frequently performed operation was ASGB (46.8%) followed by Roux-en-Y gastric bypass (38.5%).

CONCLUSION

Band migration requires band removal. Different symptoms and complications influence the kind of band removal. Multicentre data were evident in the case of high long-term complication rate after ASGB. Data of the German multicentre trial show the trend from restrictive bariatric procedures to malabsorptive approach.