Erworbene Koagulopathien

Erworbene Koagulopathien sind meist Folgen einer verursachenden Grundkrankheit (z. B. Leberinsuffizienz oder Sepsis). Die adäquate Behandlung dieser Grundkrankheit ist in der Regel von langfristig prognosebestimmender Bedeutung. Bei wenigen Koagulopathien, insbesondere bei den Immunkoagulopathien, findet sich aber keine erkennbare Grundkrankheit bei einem relevanten Anteil von Patienten. Die Optimierung der Hämostase mit dem Ziel fatale Blutungskomplikationen oder Thromboembolien zu verhindern, ist in beiden Fällen in der Lage, die Prognose zu verbessern. Meist gelingt dies durch individuell angepasste laborkontrollierte Therapien, die nur schwer einer Überprüfung im Rahmen von Studien zugänglich sind. In den vergangenen Jahren wurde erstmals in plazebokontollierten randomisierten Phase-III-Studien die Bedeutung der therapeutischen Hämostasemodulation zur Mortalitätsreduktion erfolgreich überprüft.

Impact of overall treatment time on local control of anal cancer treated with radiochemotherapy

Between 1987 and 2000, 111 patients with epidermoid anal cancer (T1-T4 Nx M0) were assigned to primary simultaneous radiochemotherapy (RCT) with a radiation dose of 45 Gy, performed either as a split course with 2-Gy single fractions (schedule A, 1987-1996, n = 65 patients) or continuously with fractions of 1.8 Gy (schedule B, 1996-2000; n = 38 patients). The chemotherapy consisted of continuous infusions of 5-fluorouracil (5-FU; 800/1,000 mg/m(2)/day, on 4/5 consecutive days, during weeks 1 and 5) together with one (schedule A) or two (schedule B) short infusions of mitomycin C (10 mg/m(2)) during the first course of 5-FU. Associations between clinical outcome and various prognostic factors were assessed in 103 patients who completed these schedules. For both patient groups combined, 5-year local control rate was 67% and 5-year survival rate 71%. Advanced tumor stage, size, and nodal status significantly decreased the 5-year local control rate as well as the overall treatment time (OTT) >41 days (58% for OTT >41 days vs. 79% for OTT < or =41 days; p = 0.04). However, we did not find a correlation with the prescribed radiotherapy schedule (A or B). In conclusion, in patients with anal carcinomas treated with RCT with a radiation dose of 45 Gy, the predominant determinant of local control is the resulting OTT and not the administration schedule (split course or continuous radiotherapy).

Intraperitoneal distribution of ultrasound contrast medium imaged with B-mode ultrasound and colour-stimulated acoustic emission imaging

Intraperitoneal port catheter systems for local delivery of cytotoxic drugs require imaging prior to chemotherapy to confirm homogenous distribution of an injected fluid in the entire peritoneal cavity. This study was performed to assess whether contrast-enhanced ultrasound (US) is a suitable imaging modality for this task. Twelve patients with peritoneal carcinosis and an implanted intraperitoneal port catheter system were studied before chemotherapy. Ultrasound examinations were performed after bolus injections of the microbubble contrast medium Levovist. Distribution of the contrast medium in the peritoneal cavity was imaged using B-mode US and colour-stimulated acoustic emission imaging (SAE). Contrast-enhanced CT imaging was used as term of reference for evaluating the US results. Distribution of the microbubbles in the peritoneal cavity was easily detected by both US methods. In 10 of 12 patients a free distribution in all abdominal quadrants was seen with both US techniques. In 2 of 12 patients, CT and US showed contrast medium limited to the perihepatic area. Therapy was stopped and surgical repositioning of the catheter was performed. Ultrasound after intraperitoneal injection of a microbubble contrast agent provides reliable information about the distribution of intraperitoneally injected fluid in the peritoneal cavity. This method is therefore well suited for imaging port catheter systems prior to chemotherapy.

Anaesthesiological experiences with whole body hyperthermia

OBJECTIVE

In order to investigate the safety of whole body hyperthermia (WBH) within the context of systemic Cancer Multistep Therapy (sCMT) in patients with disseminated malignancies, cardiopulmonary changes and various organ functions were examined.

METHODS AND PROCEDURES

Fifty-seven sCMT treatments were performed in 22 patients. WBH with a plateau phase of 1 h at 41.8 degrees C was induced by an IRATHERM 2000 device. Cardiopulmonary parameters were measured at 37, 40, 41.8 and 39 degrees C by use of a pulmonary artery catheter, femoral oxymetry and a radial artery catheter. Organ functions of the liver, kidney, cardiovascular and central nervous system were evaluated before and after treatment.

RESULTS

Compared with the initial values, significant alterations were found of most cardiopulmonary parameters in the sense of hypercirculation at 41.8 degrees C. With the exception of extra vascular lung water index, all parameters showed a clear tendency towards the pre-treatment levels at 39 degrees C. In eight out of 57 sCMT treatments, reversible organ dysfunctions were observed. Comparison of radial and femoral arterial blood pressure showed significantly different values at 40 and 41.8 degrees C.

CONCLUSIONS

WBH induces cardiovascular stress, but by careful selection of patients and appropriate anaesthesiological monitoring it can be performed safely using general anaesthesia. This enables further evaluation of WBH in multimodal treatment concepts.

Phase I study of gemcitabine in combination with cisplatin, 5-fluorouracil and folinic acid in patients with advanced esophageal cancer

The prognosis for advanced esophageal carcinoma is poor with a median survival of 9-12 months and 5-year-survival rate of 10-20%. Combination chemotherapy with cisplatin and 5-fluorouracil (5-FU) is considered to be the standard therapy, but has a high potential of side effects and is usually not given on an ambulatory basis. This phase I study was designed to find the maximum tolerated dose (MTD) of weekly cisplatin in combination with standard doses of gemcitabine (1,000 mg/m(2), 30 min) and 5-FU (750 mg/m(2), 24 h)/folinic acid (200 mg/m(2), 30 min). All drugs were to be given on a day 1, 8, 15 and 22 of a 6-weekly cycle in an outpatient setting. Nineteen chemonaive patients with inoperable stage IIa, III and IV squamous cell carcinoma and adenocarcinoma of the esophagus were enrolled into the study. Eight, six and five patients were enrolled at cisplatin dose levels 0 (20 mg/m(2) ), I (25 mg/m(2) ) and II (30 mg/m(2)), respectively. One hundred and eighty-one out of 187 treatments (55 cycles) were given on an outpatient basis. The dose-limiting toxicities of this schedule were leukopenia and thrombocytopenia. Other side effects were mild. Dose level II (30 mg/m(2)) was defined as the MTD for cisplatin when used in this combination and schedule. Partial responses were observed in 10 of the 19 enrolled patients. The side effect profile seen in this study in combination with the preliminary evidence of efficacy justifies further testing in a phase II setting with a cisplatin dose of 25 mg/m(2) and offers a treatment option for patients in an outpatient setting.

Hyperthermia in combined treatment of cancer

Hyperthermia, the procedure of raising the temperature of tumour-loaded tissue to 40-43 degrees C, is applied as an adjunctive therapy with various established cancer treatments such as radiotherapy and chemotherapy. The potential to control power distributions in vivo has been significantly improved lately by the development of planning systems and other modelling tools. This increased understanding has led to the design of multiantenna applicators (including their transforming networks) and implementation of systems for monitoring of E-fields (eg, electro-optical sensors) and temperature (particularly, on-line magnetic resonance tomography). Several phase III trials comparing radiotherapy alone or with hyperthermia have shown a beneficial effect of hyperthermia (with existing standard equipment) in terms of local control (eg, recurrent breast cancer and malignant melanoma) and survival (eg, head and neck lymph-node metastases, glioblastoma, cervical carcinoma). Therefore, further development of existing technology and elucidation of molecular mechanisms are justified. In recent molecular and biological investigations there have been novel applications such as gene therapy or immunotherapy (vaccination) with temperature acting as an enhancer, to trigger or to switch mechanisms on and off. However, for every particular temperature-dependent interaction exploited for clinical purposes, sophisticated control of temperature, spatially as well as temporally, in deep body regions will further improve the potential.

Monitoring arterial blood pressure during whole body hyperthermia

BACKGROUND

For monitoring of arterial blood pressure (ABP) during whole body hyperthermia (WBH) different methods have been recommended. This investigation was performed to evaluate the agreement of invasive measurements at various sites, and to compare invasive and non-invasive methods of ABP monitoring under conditions of a heat-induced extreme vasodilation.

METHODS

In 19 patients, 48 treatments with WBH were performed. Measurements of ABP in the radial and femoral artery by oscillometry and by sphygmomanometry were taken at four temperature levels during WBH (37, 40, 41.8 and 39 degrees C).

RESULTS

Significant differences were observed between invasive and non-invasive methods for systolic ABP, with higher values for non-invasive measurements. When compared with both invasive measurements for diastolic blood pressures, sphygmomanometry gave higher values and oscillometry gave lower values. Sphygmomanometry also showed higher values for mean ABP compared with all other techniques, while measurements in radial and femoral artery and by oscillometry only differed by approximately 5 mmHg.

CONCLUSION

The mean arterial pressure and not the systolic and/or diastolic pressure should guide hemodynamic management during WBH. The sphygmomanometric technique is not recommended for use during hyperthermia.

[Thrombophilia--diagnostic steps and therapeutic consequences after deep vein thrombosis]

SUMMARY

In developed countries there is an age dependent increasing incidence of deep vein thrombosis. Hereditary thrombophilia is usually suspected by the clinical constellation and anamnestic informations. For economical reasons usually laboratory testing should be avoided if the results will not change directly the therapeutic process. But for hereditary defects consequences for the patient in future and for relatives should be taken into account especially as more selective strategies for prophylaxis and treatment have to be expected by increasing information in that field of research. As deficiencies of anticoagulant proteins (PC, PS, AT) have an impact on anticoagulant treatment, the indication for testing should not be held too strict. Time point for diagnostic procedures should be early after a thromboembolic event as negative results exclude hereditary defects definitely which allows the planning of the aimed treatment duration. After first onset of deep vein thrombosis, even in presence of hereditary coagulation defects the duration of anticoagulation usually depends on the clinical and anamnestic signs for a thrombophilic tendency of the individual patient. First publications suggest the need for prolonged anticoagulation of carriers with combined defects, showing an elevated rate of re-thrombosis after the first thromboembolic event, when anticoagulation is stopped. Every ongoing anticoagulation should be checked repeatedly in the sense of a risk -benefit evaluation even for patients with a thrombophilic tendency and should be adapted to actual publications.

[T4 rectal carcinoma. Surgical and multimodal therapy]

BACKGROUND

In locally advanced rectal cancer with infiltration of neighbouring organs (uT4), resectability and local control are difficult to achieve. Combined preoperative radiochemotherapy may result in increased resectability and reduced local recurrence rates.

PATIENTS AND METHODS

Thirty-four patients with biopsy-proven locally advanced rectal cancer were treated by preoperative radiochemotherapy. All tumours had been staged as uT4 lesions by endorectal ultrasound or computed tomography. Radiotherapy was applied in standard blocks, 5 x 1.8 Gy up to 45 Gy. Chemotherapy consisted of two cycles of 5-fluorouracil (300-350 mg/m2/day) and leucovorin (50 mg). In 20 patients, additional thermotherapy was carried out using the Sigma 60 applicator BSD 2000 once a week prior to radiotherapy. Surgery was performed 4-6 weeks after radiochemotherapy. Postoperatively, all patients received four cycles of 5-fluorouracil and leucovorin.

RESULTS

Treatment-induced toxicity occurred in 26% of the patients (WHO grade III (n = 6) and IV (n = 3)). The resectability rate was 76% (26/34 patients) (R0 resectability n = 21; 62%). The pathological complete response rate was 6% (n = 2) and the partial response rate was 47% (n = 16). A local failure was observed in six patients after median time of 16 months (range 7-36 months). Patients with R0 resection achieved a 5-year disease-free survival rate of 55% and a survival rate of 71%. The overall 5-year survival rate for all patients with advanced uT4 rectal cancer was 49%.

CONCLUSIONS

Our data on preoperative combined treatment in locally advanced T4 rectal cancer revealed encouraging downstaging, local control, and survival rates.

[Radiological-guided liver-port implantation: Evaluation, technical approach, interventional procedure and follow up]

Radiological-guided liver-port implantation: Evaluation, technical approach, interventional procedure and follow up.

PURPOSE

Description of evaluation, technical approach, interventional procedure and follow up of radiological-guided liver-port implantation.

METHOD

Percutaneous implantation of a liver-port system was performed in twelve patients through a transfemoral approach and in one patient via the superficial epigastric artery after surgical exploration. In four patients we used port systems which are accessible via ventral puncture. Strecker-port systems were implanted in the remaining nine patients.

RESULTS

The liver-port implantation was technically successful in all cases. No dislocation of the distal catheter tip, no thrombosis of the hepatic or splenic artery, no leakage near connections of the catheters or connections of catheter and port system and no thrombosis of the femoral arteries were observed. Correction of a kink in the catheter was performed in one patient. Another patient showed prolonged healing of the subcutaneous pocket.

CONCLUSIONS

Interventional liver-port implantation is a safe procedure and leads to good clinical results. From the view of the radiologist the Strecker-system shows a good performance. The approach via the superficial epigastric artery demands excellent interdisciplinary cooperation.

Platelet activation through triathlon competition in ultra-endurance trained athletes: impact of thrombin and plasmin generation and catecholamine release

The aims of this study were to evaluate whether platelets are activated during strenuous exercise in healthy athletes. Also, to determine the impact of plasmin and thrombin activity and catecholamine release. Previous studies have shown activation of the hemostatic system after competitive exercise, but platelet activation was thought to be absent in trained athletes. The impact of thrombin and other potent platelet activators is still a matter for debate. We examined 30 healthy triathletes during a triathlon competition. Flow cytometric detection of CD62p (P-selectin) was used to measure in vivo activation of platelets. Platelet-leukocyte aggregates were also determined. Thrombin concentration was assessed by the thrombin-antithrombin III complex (TAT) and the fibrinolytic state was characterised by the plasmin-alpha2-antiplasmin complex (PAP). Catecholamines were measured by means of high-pressure liquid chromatography. CD62p rose from baseline (2.3%) to 3.4% and was still elevated after 2 hours (3.1%, p = 0.0133). Platelet-leukocyte aggregates were elevated 30 min after exercise (4.3 % vs 3.6%) and decreased significantly after 60 min (2.9 %, p = 0.008). TAT increased from 3.9 microg/l to 8.3 microg/l after competition and to 5.4 microg/l 2 hours later (p < 0.001). PAP increased 10-fold from 350 microg/l to 3,267 microg/l after the triathlon and was still elevated after 2 hours (1,074 microg/l, p<0.001). No linear correlation was found between the hemostatic markers, catecholamines and platelet activation. Platelets, coagulation and fibrinolysis are activated by competitive exercise in athletes, whereby fibrinolytic changes are pronounced. Mechanisms of platelet activation during exercise include phenomena other than plasmatic hemostatic factors and catecholamines.

[Secondary osteoporosis induced by anticoagulants?]

Generalized osteoporosis is a result of different causes and pathogenic mechanisms, which often combine forces to become clinically relevant. Among the different exogenic factors, drugs play an important role, frequently in connection with other factors such as immobilization or pregnancy. It has been suggested that anticoagulation therapy with heparins or coumarins may induce osteoporotic changes or enhance the development of osteoporosis for other reasons. According to in vitro experiments, preclinical trials, and clinical investigations, it seems reasonable to assume that heparins induce increased bone loss in a time- and dose-related manner. Low-molecular-weight heparins most likely have less effect on bone turnover when compared to unfractionated heparin. Oral anticoagulation therapy with vitamin K-antagonists is believed to have a weak effect on induction of osteoporosis, but clinical studies are contradictory. In spite of the fact that a relevant effect of these drugs on the induction of osteoporosis is questionable, it must be taken into consideration that anticoagulant drugs may enhance the negative effects on bone density of other risk factors capable of inducing osteoporosis such as immobilization, pregnancy, or endocrinological disorders.

Anticoagulation: the present and future

Thrombin is a central bioregulator of coagulation and is therefore a key target in the therapeutic prevention and treatment of thromboembolic disorders, including deep vein thrombosis and pulmonary embolism. The current mainstays of anticoagulation treatment are heparins, which are indirect thrombin inhibitors, and coumarins, such as warfarin, which modulate the synthesis of vitamin K-dependent proteins. Although efficacious and widely used, heparins and coumarins have limitations because their pharmacokinetics and anticoagulant effects are unpredictable, with the risk of bleeding and other complications resulting in the need for close monitoring with their use. Low-molecular-weight heparins (LMWHs) provide a more predictable anticoagulant response, but their use is limited by the need for subcutaneous administration. In addition, discontinuation of heparin treatment can result in a thrombotic rebound due to the inability of these compounds to inhibit clot-bound thrombin. Direct thrombin inhibitors (DTI) are able to target both free and clot-bound thrombin. The first to be used was hirudin, but DTIs with lower molecular weights, such as DuP 714, PPACK, and efegatran, have subsequently been developed, and these agents are better able to inhibit clot-bound thrombin and the thrombotic processes that take place at sites of arterial damage. Such compounds inhibit thrombin by covalently binding to it, but this can result in toxicity and nonspecific binding. The development of reversible noncovalent DTIs, such as inogatran and melagatran, has resulted in safer, more specific and predictable anticoagulant treatment. Oral DTIs, such as ximelagatran, are set to provide a further breakthrough in the prophylaxis and treatment of thrombosis.

[Radiochemotherapy plus hyperthermia in rectal carcinoma]

In locally advanced rectal cancer (uT3/uT4) resectability as well as local control is reduced. In the patients combined preoperative radiochemotherapy demonstrated an increase of resectability and a reduction of local recurrence. Radiotherapy was applied in standard blocks, 5 x 1.8 Gy up to 45 Gy. Chemotherapy consisted out of two cycles of 5-Fluorouracil (300-350 mg/m2/d) and Leucovorin (50 mg). Prior to radiotherapy additionally thermotherapy was carried out using the SIGMA 60 applicator BSD 2000 once a week. The hyperthermia method is based on heating up affected tissue compartments to temperature above 42 degrees Celsius without damaging surrounding tissue compartments. In regional hyperthermia tumors in the abdominal region are treated by emitting radio waves into the patient. 4-6 weeks after radiochemotherapy, surgery was performed. The therapeutic toxicity was acceptable and the resectability rate was up to 90%. Response rate to treatment was 60%. Our data with preoperative combined treatment in locally advanced rectal cancer revealed encouraging downstaging, local control, and survival rates.

Recombinant human erythropoietin in the treatment of head and neck tumour anaemia

At the time of first diagnosis, patients with squamous cell carcinoma in the head and neck are often in the advanced stage of their disease, therefore surgery is not a viable option for treatment. These patients also present frequently a high grade of anaemia as a result of either the malignant process itself or of the following therapy. The incidence of anaemia and the need for transfusion depends on several factors, such as the type and intensity of radiotherapy and radiochemotherapy. Multimode therapeutic concepts such as radio-chemotherapy are being applied with increasing frequency, resulting in an ever increasing need for transfusion with great effects on the patient's quality of life. Even more important to tumour patients is the role of the haemaglobin (Hb) value as a prognostic factor for survival and/or local tumour control. A large number of studies show that recombinant human erythropoietin (r-HuEPO) is effective in the treatment of tumour-induced anaemia and prevention and correction of chemotherapy and radiotherapy-induced anaemia. The simultaneous application of r-HuEPO with chemotherapy can prevent patients with head and neck tumours from developing anaemia or can reduce the extent of the anaemia and the need for transfusion. Comparable effects were observed both in patients undergoing platinum-based and non-platinum-based chemotherapy. The direct correlation between anaemia, tumour hypoxia and poor response to radio and/or chemotherapy has been clinically proven. Recombinant human erythropoietin administration improves the therapeutic outcome and the patients' prognosis.