Influence of neoadjuvant radiochemotherapy combined with hyperthermia on the quality of life in rectum cancer patients

PURPOSE

The present study compares quality of life (QoL) after neoadjuvant radiochemotherapy with or without hyperthermia in patients with advanced rectal cancer.

METHODS

Between April 1994 and May 1999, 137 patients were treated by neoadjuvant radiochemotherapy with (69 patients (50.4%)) or without (68 patients (49.6%)) hyperthermia. Forty-six patients (33.6%) filled-out a 'Gastrointestinal Quality of Life Index' (GIQLI) questionnaire at four time points (before and after neoadjuvant therapy, early after surgery and after long-term follow-up) and were included in the present study.

RESULTS

There were no statistically significant differences in the global GIQLI index between patients treated with neoadjuvant radiochemotherapy with and without hyperthermia at any time point. The longitudinal analysis of GIQLI values in both treatment groups showed specific profiles that were identical in both treatment groups. Occurrence of severe toxicity during the neoadjuvant therapy in both arms lead to a significant temporary reduction of QoL scores at TP2 without any detrimental long-term effects. Patients with sphincter preservation and patients with sphincter resection reported similar QoL scores during long-term follow-up.

CONCLUSION

Neoadjuvant radiochemotherapy with and without hyperthermia has similar effects on the QoL of patients with locally advanced rectal cancer. The addition of hyperthermia during the neoadjuvant therapy with the potentially associated inconveniences has no negative effects on QoL.

CONKO-101: Results of a multicenter phase II study of an outpatient regimen consisting out of gemcitabine, 5-FU (24h CI), folinic acid and cisplatin for patients with inoperable esophageal cancer

4066

Background: Standard therapy for inoperable esophageal cancer is a combination of cisplatin and 5-FU combined with radiation for locally advanced stages. As gemcitabine shows synergy with cisplatin and 5-FU, we evaluated the combination of cisplatin 30 mg/m2 (90 min), Gemcitabine 1000 mg/m2 (30 min), FS 200 mg/m2 (30 min) and 5-FU 750 mg/m2 24h CI) d1,8 q d22 for patients with inoperable esophageal cancer. For locally advanced stages, patients received sequential radiochemotherapy with 5-FU CI. Methods: 89 (75 m/14 w) pts. were included into this multicentrical phase 2 study. 58 had SCC, 30 AC, 1 pt. had undifferentiated carcinoma. Median age was 61 (22–86), Median KI 90 (60–100). 2 pts. had stage IIa, 4 stage IIb, 30 stage III, 16 stage IVa and 37 stage IVb. Results: 71 pts. are so far evaluable for response and 84 for toxicity. 2 pts. (2.8%) had CR (1 pathologically confirmed), 27 pts. had PR (38.1%), 33 pts. had SD (46.5%) and 9 pts. had PD (12.6%) as best response. MS was 10.7 months (13.1 for stage II/III and 9.1 for stage IV). Median TTP was 6 months, and PFS was 6 months. Observed toxicity was low and predominantly hematologic with Leukopenia Grade III/IV in 10% of cycles, Hb Grade III/IV in 5.3% of cycles and Thrombopenia Grade III/IV in 2.4% of cycles. Conclusion: This regimen is well tolerable and can easily be applied on an outpatient base. The remission rates and survival data are within the range previously reported in other phase II studies.

No significant financial relationships to disclose.

A prospective, randomized trial of simultaneous pancreatic cancer treatment with enoxaparin and chemotherapy (PROSPECT - CONKO 004)

4110

Background: Approximately 20% of patients (pts) diagnosed with pancreatic adenocarcinoma (PA) develop venous thromboembolism, which may contribute to the dismal prognosis of PA. A small phase II trial suggested an improved survival by the addition of low molecular weight heparin (LMWH) to chemotherapy (Icli et al., ASCO 2003). We conducted a small pilot study which indicated that the addition of enoxaparin to chemotherapy GFFC chemotherapy (see below) is safe and feasible in pts with advanced PA. Furthermore, results of several phase III studies suggest that pts in good performance status may benefit from more intensive chemotherapy regimen (Riess et al; Heinemann et al; ASCO 2005). Based on these considerations we started the multicenter phase III study CONKO 004. Methods: 540 patients are to be recruited into this study. Primary stratification takes place according to Karnowsky performance status and kidney function. Patients with KPS > 80% and normal kidney function receive GFFC ± LMWH (gemcitabine 1 g/m2 (30 min), cisplatin 30 mg/m2 (90 min), 5-fluorouracil 750 mg/m2 (24 h), folinic acid 200 mg/m2 (30 min), d1, 8; q3w ± Enoxaparin 1mg/kg daily s.c.). Pts with KPS < 80 % and increased creatinin plasma levels (>1.3 mg/dl) receive the current standard therapy (gemcitabine 1 g/m2 (30 min), d1, 8, 15; q4w) ± LMWM ± Enoxaparin 1mg/kg daily s.c. After 12 weeks of initial chemotherapy all patients who have not progressed received the standard therapy (gemcitabine 1 g/m2 (30 min), d1, 8, 15; q4w) ± Enoxaparin 40mg daily s.c. Results: From April 2004 to Dezember 2005 140 pts have been recruited in this study. Until now no unexpected serious adverse events concerning severe bleedings were observed in the enoxaparin treatment group. No heparin induced thrombocytopenia (HIT II) was documented. The first interim analysis per protocol is planned after 12 pts. with deep vein thrombosis or thromboembolic events. This interim analysis is expected to be completed in May 2006. Conclusions: Our observations indicate that the addition of enoxaparin—given the dosage mentioned above—to GEM/GFFC is safe, does not change toxicity and maintains activity of chemotherapy in pts with advanced PA. This study is open to recruitment.

No significant financial relationships to disclose.

Evaluation of patients with liver metastases from colorectal cancer for locally ablative treatment with laser induced thermotherapy. Impact of PET with 18F-fluorodeoxyglucose on therapeutic decisions

PURPOSE

Before locally ablative treatment of colorectal liver metastases, patients have to be carefully evaluated to decide whether this is the adequate therapy. In this study we determined the value of FDG-PET in comparison to conventional staging procedures.

PATIENTS, METHODS

In 68 consecutive patients referred for laser induced thermotherapy (LITT) of liver metastases from colorectal cancer, pretherapeutic staging with conventional imaging (thoracic and abdominal CT, liver MRI, chest X-ray) and FDG-PET was performed. The examinations were analysed separately and blinded. Based on the staging information, therapeutic decisions were made by an interdisciplinary review board according to a standardized algorithm. The results were compared between conventional imaging and FDG-PET, and were validated by clinical follow up data and histopathology, respectively.

RESULTS

On FDG-PET 210 lesions were interpreted as tumour manifestations. 48 of these were not seen on conventional imaging (true positive, n = 46). In contrast, 24 lesions were visualized by conventional imaging only (true positive, n = 12). Compared to conventional imaging, discrepant findings on FDG-PET led to treatment modifications in 25 patients (37%); these were correct in 20/25 patients. According to the actual treatment course, the inadequate treatment modifications in the remaining 5 patients were avoided by further diagnostic procedures (i.e. biopsies).

CONCLUSION

In the evaluation of patients with known liver metastases from colorectal cancer before LITT, FDG-PET depicts relevant findings subsidiary to conventional imaging and thus is of high value for therapeutic decision making.

Gemcitabine in the treatment of advanced head and neck cancer

AIMS

Several new chemotherapy agents show varying degrees of activity in head and neck cancer. One of them is gemcitabine, which is a new nucleoside analogue with an innovative cytostatic mode of action. Gemcitabine has demonstrated a broad spectrum anti-tumoural effect and a favourable toxicity profile. These attributes prompted us to introduce gemcitabine into the treatment of head-and-neck tumours.

MATERIALS AND METHODS

Ten heavily pre-treated patients with recurrent and incurable squamous-cell carcinoma of the head and neck (SCCHN) were treated with Gem. The initial cycle consisted of six administrations of the drug (1250 mg/m2 once weekly intravenously over 30 min) followed by a week without cytotoxic treatment. All following cycles were composed of two infusions once weekly (d1, 8), followed by a week of rest.

RESULTS

Toxic effects, length of survival and tumour response was assessable in eight patients owing to one suicide and loss of one patient for follow-up. One complete remission, two partial remissions and three 'no change' situations (stable disease) were observed, yielding a response rate of 37.5%. Median survival was 8 months (range 3-12). The incidence of haematological toxicity was low, with grade 3-4 neutropenia in less than 10%. Flu-like symptoms were reported by one-third of patients.

CONCLUSIONS

In this small phase-II study, gemcitabine demonstrated a high anti-tumoural activity in SCCHN, with a favourable toxicity profile. Gemcitabine seems to be a promising new drug without severe burden even for patients who are refractory to other cytostatic drugs. Within recent years, the activity and tolerability of gemcitabine was documented in several phase I and phase II trials, especially in combination with cisplatin, and paclitaxel resp, carboplatin/paclitaxel, cisplatin/ifosfamide, and 5-fluorouracil/paclitaxel. The results of these trials will be outlined in the discussion.

Current status of radiant whole-body hyperthermia at temperatures >41.5 degrees C and practical guidelines for the treatment of adults. The German 'Interdisciplinary Working Group on Hyperthermia'

The term 'extreme' whole-body hyperthermia (WBH) describes the procedure of raising a patients' body-core temperature to 41.5-42.0 degrees C for 60 min. WBH represents the only hyperthermia technique that enables systemic heat treatment in patients with disseminated malignancies and is, therefore, usually combined with systemic chemotherapy. Up to now, several WBH-approaches have proved to be safe and associated with acceptable toxicity rates when radiant heat devices are employed. Until the late 1990s, the use of radiant WBH was restricted to a few specialized treatment centres worldwide. During the last 5 years, a larger number of WBH-devices were put into operation particularly in Germany. As a result, a novel generation on phase II trials on chemotherapy and adjunctive WBH in patients with various malignancies has been completed. Based on the promising results observed herein, first multi-centric phase III-trials on chemotherapy +/- WBH have been initiated, with a considerable number of patients treated at German institutions. The authors are members of the 'Interdisciplinary Working Group for Hyperthermia' ('Interdisziplinäre Arbeitsgruppe Hyperthermie'), a sub-group of the German Cancer Society. They formulated these guidelines in order to standardize the WBH treatment procedure and supportive measures, to provide some uniformity in the selection of patients to be treated and to define criteria of a successful WBH-treatment. These recommendations may be helpful to ensure the quality of WBH performed at different institutions.

[Basics in the pathophysiology of sepsis]

Within the recent years preclinical and clinical investigations to a great extend increased the pathophysiological understanding what is going on in patients with severe sepsis. It became evident, that not the initiating infection by itself is the main reason for the severity and limited prognosis in sepsis. More important is the unbalanced reaction of the patient's organism to this infection, which is reflected in a mainly cytokine driven inflammation, the so called systemic inflammatory response syndrome, with its consequences. In the context of this syndrome released mediators, in part together with toxins from infectious microorganisms, result in a systemic activation of haemostasis. In the centre of our pathophysiologic model are the activations of the monocyte/macrophage-system and of the endothelium. This results in the activation of plasmatic cascades including the coagulation and fibrinolysis systems. The observed activation of haemostasis and inhibition of fibrinolysis in patients with sepsis by themselves interact with leukocytes and endothelium and play an important role in the progressive derangement of microcirculation. This is clinically reflected in organ dysfunctions. Within a single individual patient there is increased fibrin formation, decreases in coagulation factors, inhibitors and platelets, as well as defects of the fibrinolytic system in parallel that may clinically result in disseminated intravascular coagulation with the risk of bleeding complications in addition to organ dysfunctions.

[Therapeutic modulation of coagulation in sepsis]

Based on the increasing knowledge of defects in haemostasis in patients with sepsis as well as on the non-conclusive results of studies which tried to increase the prognosis by modulating cytokine response of the patients, in the last years the impact of therapeutic modulation of coagulation in sepsis has been investigated. In contrast to the results of phase III studies with the coagulation inhibitors antithrombin and tissue factor pathway inhibitor recombinant human activated protein C (rhAPC) resulted in a significant reduction in mortality for the whole study population. Data analyses showed, that treatment with rhAPC was clinically beneficial especially in patient groups who showed a high mortality in the placebo arm. Inhibition of thrombus formation due to the therapy with natural coagulation inhibitors resulted in an increase of sepsis-imminent haemorrhage, which became significant in some studies. Treatment with antithrombin and heparin resulted in a considerable increase in bleeding complications and on the other hand, may have antagonized the expected effect of antithrombin on the patient's prognosis. Some results suggesting beneficial effects of heparin on patient prognosis in the placebo arms and on the other hand negative effects of heparin in the verum arms -- especially with antithrombin or tissue factor pathway inhibitor -- let to a controversial discussion of the risk/benefit relation of heparin, given in prophylactic doses to patients with severe sepsis. Whereas the impact and optimal application of heparin to patients with severe sepsis needs to be clarified study results with rhAPC resulted in the approval of this therapy and the implementation in the guidelines of the treatment of patients with severe sepsis.

Treatment of locally recurrent rectal cancer with special focus on regional pelvic hyperthermia

Progress in surgery and adjuvant therapy has markedly improved local control and survival rates in patients with primary, non-metastatic rectal cancer. However, the prognosis of patients with locally recurrent disease is still poor, and a realistic chance for repeated treatment with curative intent is still restricted to the minority of cases. Therefore, effective palliation of symptoms and preservation of a good quality of life are the major goals of therapy for most patients with local recurrence of rectal cancer. Here we give a short overview on the options available for the treatment of pelvic recurrence of rectal cancer, with special focus on adjunctive regional pelvic radiofrequency hyperthermia.

Gerinnungstherapeutische Ansätze bei Sepsis

Ausgehend von dem zunehmenden Verständnis der bei Patienten mit Sepsis beobachteten Gerinnungsstörung sowie den bisher erfolglosen Versuchen durch Modulation der Zytokinantwort die Prognose von Sepsispatienten zu verbessern, wurden in den vergangenen Jahren gerinnungstherapeutische Ansätze der Sepsisbehandlung intensiver untersucht. Während die Phase-III-Studien mit den Gerinnungsinhibitoren, Antithrombin und TFPI (tissue factor pathway inhibitor) für das Gesamtkollektiv der Patienten mit schwerer Sepsis keine Prognoseverbesserung zeigten, fand sich für rekombinantes humanes aktiviertes Protein C (rhAPC) eine signifikante, 19%ige relative Reduktion der Sterblichkeit. Weitere Analysen verdeutlichten, dass die Therapie mit rhAPC insbesondere bei Patientengruppen mit hoher Sterblichkeit im Plazeboarm zu klinisch relevanten Ergebnisverbesserungen führt.

Die durch natürliche Gerinnungsinhibitoren bewirkte Hemmung der Gerinnselbildung, spiegelt sich in allen drei Studien in einer, z.T. signifikanten Zunahme der Sepsis-immanenten Blutungsneigung wider, wobei im Falle von Antithrombin die gleichzeitige Heparingabe das Blutungsrisiko deutlich erhöht und möglicherweise dem erhofften Antithrombineffekt auf die Patientenprognose entgegenwirkt. Hinweise auf einen möglicherweise positiven Effekt von Heparin in den Plazeboarmen einerseits, andererseits auf nachteilige Effekte von Heparin in den Therapiearmen (v. a. mit Antithrombin bzw. TFPI) führen zur kontroversen Diskussion des Nutzen/Risiko-Verhältnisses von Heparin in prophylaktischer Dosis bei Patienten mit schwerer Sepsis. Während die Bedeutung und optimale Applikation von Heparin bei schwerer Sepsis der weiteren Klärung bedarf, haben die Studiendaten zu rhAPC zur Zulassung dieses Therapieprinzips und seiner Verankerung in den Empfehlungen zur Behandlung von Patienten mit schwerer Sepsis geführt.

[Acquired blood coagulation disorders]

Acquired coagulopathies regularly result from underlying diseases such as liver failure or sepsis. Optimal treatment of these underlying diseases defines longterm prognosis. In a few coagulopathies, such as immunocoagulopathies, in a relevant portion of patients an underlying disease cannot be identified. Therapeutic modulation of haemostasis aiming at the prevention of fatal bleeding or thromboembolism is able to improve the prognosis of patients with acquired coagulopathies. Most often this is the result of individualized, lab-controlled treatments, which are difficult to be studied. Within the last years the role of therapeutic modulation of haemostasis to reduce mortality was successfully studied for the first time in the frame of randomized placebo-controlled phase III studies.

Whole-body hyperthermia in the scope of von Ardenne's systemic cancer multistep therapy (sCMT) combined with chemotherapy in patients with metastatic colorectal cancer: a phase I/II study

This phase I/II study evaluated the feasibility, toxicity and response rates of von Ardenne's systemic cancer multistep therapy (sCMT) when applied as an adjunct to cytostatic therapy in patients with metastatic colorectal cancer. sCMT consists of whole-body hyperthermia (WBH) at 41.8-42.1 degrees C, hyperglycaemia and hyperoxaemia. All patients who entered the trial first received three monthly courses of chemotherapy (folinic acid, 50 mg, days 1-5; 5-fluorouracil, 425 mg/m2, days 1-5; mitomycin 8 mg/m2, day 1), followed by response evaluation according World Health Organization (WHO) criteria. Responders (partial/complete remission) were assigned to three further courses of chemotherapy, whereas non-responders (stable/progressive disease) were allocated to additional sCMT on day 1 of every subsequent chemotherapy course. The WBH procedure was administered under general anaesthesia employing the Iratherm-2000 radiant heat device. Of 28 patients enrolled, 19 received more than three treatment courses. Eight of these 19 patients had responded to chemotherapy (PR) and thus obtained three further courses of chemotherapy alone. In 10 of 19 patients who had not responded (SD, PD), three additional courses of chemotherapy were combined with sCMT (with 25 sCMT applications). One patient who did not respond to initial treatment declined sCMT and was continued with chemotherapy alone. It was found that sCMT was feasible, but associated with a specific spectrum of grade III/IV toxicity (skin 20%, pain 16%, peripheral nerves 8% of treatment courses). The fact that three patients who did not respond to initial chemotherapy achieved a PR after additional sCMT suggests that sCMT may enhance the effect of chemotherapy in patients with colorectal cancer.

MRI after magnetic drug targeting in patients with advanced solid malignant tumors

The purpose of this study was to evaluate the ability of MRI to detect magnetic particle uptake into advanced solid malignant tumors and to document the extension of these tumors, carried out in the context of magnetic drug targeting. In a prospective phase I trial, 11 patients were examined with MRI before and after magnetic drug targeting. The sequence protocol included T1-WI and T2-WI in several planes, followed by quantitative and qualitative evaluation of the signal intensities and tumor extensions. In nine patients, a signal decrease was observed in the early follow-up (2-7 days after therapy) on the T2-weighted images; two patients did not show a signal change. The signal changes in T1-WI were less distinct. In late follow-up (4-6 weeks after therapy), signal within nine tumors reached their initially normal level on both T1-WI and T2-WI; two tumors showed a slight signal decrease on T2-WI and a slight signal increase on T1-WI. Within the surveillance period, tumor remission in 3 out of 11 patients was observed, and in 5 patients tumor growth had stopped. The remaining three patients showed significant tumor growth. There was no statistically significant correlation between signal change and response. MRI is a suitable method to detect magnetite particles, deposited at the tumor site via magnetic drug targeting. MRI is therefore eligible to control the success of MDT and to assess the tumor size after the end of therapy.