First-in-class MKK4 inhibitors enhance liver regeneration and prevent liver failure

Diminished hepatocyte regeneration is a key feature of acute and chronic liver diseases and after extended liver resections, resulting in the inability to maintain or restore a sufficient functional liver mass. Therapies to restore hepatocyte regeneration are lacking, making liver transplantation the only curative option for end-stage liver disease. Here, we report on the structure-based development and characterization (nuclear magnetic resonance [NMR] spectroscopy) of first-in-class small molecule inhibitors of the dual-specificity kinase MKK4 (MKK4i). MKK4i increased liver regeneration upon hepatectomy in murine and porcine models, allowed for survival of pigs in a lethal 85% hepatectomy model, and showed antisteatotic and antifibrotic effects in liver disease mouse models. A first-in-human phase I trial (European Union Drug Regulating Authorities Clinical Trials [EudraCT] 2021-000193-28) with the clinical candidate HRX215 was conducted and revealed excellent safety and pharmacokinetics. Clinical trials to probe HRX215 for prevention/treatment of liver failure after extensive oncological liver resections or after transplantation of small grafts are warranted.

Effect of Hyperthermic Intraperitoneal Chemotherapy on Cytoreductive Surgery in Gastric Cancer With Synchronous Peritoneal Metastases: The Phase III GASTRIPEC-I Trial

PURPOSE

In patients with peritoneal metastasis (PM) from gastric cancer (GC), chemotherapy is the treatment of choice. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are still being debated. This randomized, controlled, open-label, multicenter phase III trial (EudraCT 2006-006088-22; ClinicalTrials.gov identifier: NCT02158988) explored the impact on overall survival (OS) of HIPEC after CRS.

PATIENTS AND METHODS

Adult patients with GC and histologically proven PM were randomly assigned (1:1) to perioperative chemotherapy and CRS alone (CRS-A) or CRS plus HIPEC (CRS + H). HIPEC comprised mitomycin C 15 mg/m2 and cisplatin 75 mg/m2 in 5 L of saline perfused for 60 minutes at 42°C. The primary end point was OS; secondary endpoints included progression-free survival (PFS), other distant metastasis-free survival (MFS), and safety. Analyses followed the intention-to-treat principle.

RESULTS

Between March 2014 and June 2018, 105 patients were randomly assigned (53 patients to CRS-A and 52 patients to CRS + H). The trial stopped prematurely because of slow recruitment. In 55 patients, treatment stopped before CRS mainly due to disease progression/death. Median OS was the same for both groups (CRS + H, 14.9 [97.2% CI, 8.7 to 17.7] months v CRS-A, 14.9 [97.2% CI, 7.0 to 19.4] months; P = .1647). The PFS was 3.5 months (95% CI, 3.0 to 7.0) in the CRS-A group and 7.1 months (95% CI, 3.7 to 10.5; P = .047) in the CRS + H group. The CRS + H group showed better MFS (10.2 months [95% CI, 7.7 to 14.7] v CRS-A, 9.2 months [95% CI, 6.8 to 11.5]; P = .0286). The incidence of grade ≥3 adverse events (AEs) was similar between groups (CRS-A, 38.1% v CRS + H, 43.6%; P = .79).

CONCLUSION

This study showed no OS difference between CRS + H and CRS-A. PFS and MFS were significantly better in the CRS + H group, which needs further exploration. HIPEC did not increase AEs.

Regional hyperthermia with cisplatin added to gemcitabine versus gemcitabine in patients with resected pancreatic ductal adenocarcinoma: The HEAT randomised clinical trial

BACKGROUND

Regional hyperthermia (RHT) with cisplatin added to gemcitabine showed efficacy in gemcitabine-pre-treated patients with advanced pancreatic ductal adenocarcinoma. We conducted a randomised clinical trial to investigate RHT with cisplatin added to gemcitabine (GPH) compared with gemcitabine (G) in the adjuvant setting of resected pancreatic ductal adenocarcinoma.

METHODS

This randomised, multicentre, open-label trial randomly assigned patients to either GPH (gemcitabine 1000 mg/m² on day 1, 15 and cisplatin 25 mg/m² with RHT on day 2, 3 and 15,16) or to G (gemcitabine 1000 mg/m² on day 1,8,15), four-weekly over six cycles. Disease-free survival (DFS) was the primary end-point. Secondary end-points included overall survival (OS) and safety.

RESULTS

A total of 117 eligible patients (median age, 63 years) were randomly allocated to treatment (57 GPH; 60 G). With a follow-up time of 56.6 months, the median DFS was 12.7 compared to 11.2 months for GPH and G, respectively (p = 0.394). Median post-recurrence survival was significantly prolonged in the GPH-group (15.3 versus 9.8 months; p = 0.031). Median OS reached 33.2 versus 25.2 months (p = 0.099) with 5-year survival rates of 28.4% versus 18.7%. Excluding eight patients who received additional capecitabine in the G-arm (investigators choice), median OS favoured GPH (p = 0.052). Adverse events CTCAE (Common Terminology Criteria for Adverse Events) grade ≥3 occurred in 61.5% (GPH) versus 63.6% (G) of patients. Two patients in the G-group died because of treatment-related toxic effects.

CONCLUSIONS

The randomised controlled Hyperthermia European Adjuvant Trial study failed to demonstrate a significant difference in DFS. However, it suggests a difference in post-recurrence survival and a trend for improved OS.

CLINICALTRIALS

gov, number NCT01077427.

Beware of gastric tube in esophagectomy after gastric radiotherapy: A case report

BACKGROUND

Gastric tube formation and pull-up is the most common technique of reconstruction following esophagectomy for esophageal cancer. If previous treatment with radiotherapy for gastric mucosa-associated lymphoid tissue (MALT)-lymphoma restricts suitability of the stomach for anastomosis to the esophagus is unknown.

CASE SUMMARY

A 57-year-old man underwent sequential chemotherapy and radiotherapy for gastric MALT-lymphoma seven years prior to diagnosis of esophageal adenocarcinoma. Esophagectomy without neoadjuvant treatment was recommended by the multidisciplinary tumor board due to early tumor stage [uT1 (sm2) uN+ cM0 according to TNM-classification of malignant tumors, 8^th edition] without lymph node involvement. Minimal invasive esophageal resection with esophagogastrostomy was performed. Due to gastric tube necrosis with anastomotic leakage on the twelfth postoperative day, diverting resection with construction of a cervical salivary fistula was necessary. Rapid recovery facilitated colonic interposition without any complications six months afterwards.

CONCLUSION

This case report may represent the start for further investigation to know if it is reasonable to refrain from esophagogastrostomy in patients with a long interval between gastric radiotherapy and surgery.

Applying the Delphi process for development of a hepatopancreaticobiliary robotic surgery training curriculum

BACKGROUND

Robotic hepatopancreaticobiliary (HPB) procedures are performed worldwide and establishing processes for safe adoption of this technology is essential for patient benefit. We report results of the Delphi process to define and optimize robotic training procedures for HPB surgeons.

METHODS

In 2019, a robotic HPB surgery panel with an interest in surgical training from the Americas and Europe was created and met. An e-consensus-finding exercise using the Delphi process was applied and consensus was defined as 80% agreement on each question. Iterations of anonymous voting continued over three rounds.

RESULTS

Members agreed on several points: there was need for a standardized robotic training curriculum for HPB surgery that considers experience of surgeons and based on a robotic hepatectomy includes a common approach for "basic robotic skills" training (e-learning module, including hardware description, patient selection, port placement, docking, troubleshooting, fundamentals of robotic surgery, team training and efficiency, and emergencies) and an "advanced technical skills curriculum" (e-learning, including patient selection information, cognitive skills, and recommended operative equipment lists). A modular approach to index procedures should be used with video demonstrations, port placement for index procedure, troubleshooting, and emergency scenario management information. Inexperienced surgeons should undergo training in basic robotic skills and console proficiency, transitioning to full procedure training of e-learning (video demonstration, simulation training, case observation, and final evaluation). Experienced surgeons should undergo basic training when using a new system (e-learning, dry lab, and operating room (OR) team training, virtual reality modules, and wet lab; case observations were unnecessary for basic training) and should complete the advanced index procedural robotic curriculum with assessment by wet lab, case observation, and OR team training.

CONCLUSIONS

Optimization and standardization of training and education of HPB surgeons in robotic procedures was agreed upon. Results are being incorporated into future curriculum for education in robotic surgery.

Cost-effectiveness analysis of pressurized intraperitoneal aerosol chemotherapy (PIPAC C/D) in patients with gastric cancer and peritoneal metastasis

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Background: The efficacy of systemic chemotherapy is still highly unsatisfactory for patients with gastric cancer and peritoneal metastases (PM). The aim of this study was to assess the costs effectiveness of pressurized intraperitoneal aerosol chemotherapy with low-dose cisplatin and doxorubicin (PIPAC C/D) for advanced gastric cancer. Methods: We developed a state transition Markov Model to estimate the costs and effectiveness of the use of PIPAC C/D versus palliative chemotherapy. Intervention was assessed in two different levels including upfront therapy (PIPAC C/D plus XELOX chemotherapy versus first-line chemotherapy alone) and second line therapy (PIPAC C/D only versus second-line chemotherapy (ramucirumab monotherapy)). Data from multiple sources such as published literature and UK-based databases were used to inform the economic model. Deterministic and probabilistic sensitivity analyses were conducted to explore the impact of key parameter variation on the results. Results: For the upfront therapy the estimated total costs in the intervention and comparator arms were £33,587(SD: £2,394) and £17,477 (£927) respectively. PIPAC C/D plus XELOX led to an increase of 0.56 in QALYs. Estimated incremental cost per quality adjusted life years (QALYs) was £28,879. Result from probabilistic sensitivity analysis showed that PIPAC C/D plus XELOX is cost effective in more than 50% of Monte Carlo simulations at £30,000 threshold. For the second-line therapy, the total costs for PIPAC C/D was £15,985 (£1,391) and for the second-line palliative chemotherapy was £36,319 (£3,673). PIPAC C/D led to an increase of 0.21 in QALYs and £20,222 reduction in costs, meaning the intervention is dominant strategy in the second line therapy as it is less costly and more effective. Conclusions: The cost effectiveness results for the upfront therapy indicate that PIPAC C/D plus chemotherapy intervention is more costly and more effective and a cost effective intervention. PIPAC C/D only intervention has the potential to reduce costs and improve clinical outcomes for patients with advanced gastric cancer with peritoneal metastasis and therefore a dominant strategy.

Randomized clinical trial of platysma muscle suture versus no suture for wound closure after thyroid surgery

Background

Suturing the platysma muscle during wound closure after thyroid surgery is frequently described in the literature. There is no prospective evidence to support its use or benefit. The aim of this study was to evaluate how a platysma muscle suture influences initial postoperative pain following thyroid surgery.

Methods

Patients were assigned randomly to receive a platysma suture or no platysma suture in this prospective, patient-blinded trial. The duration of follow-up was 6 months. The primary endpoint was wound-specific pain 24 h after thyroid resection. Secondary endpoints were intraoperative and perioperative analgesia requirement, postoperative pain and complications until postoperative day 14, and Patient and Observer Scar Assessment Score (POSAS) 6 months after surgery.

Results

Forty-one patients were randomized to each group. Visual analogue scale scores for wound-specific pain were lower in patients without a platysma suture 24 h after surgery (mean(s.d.) 3·15(1·46) versus 2·17(1·41) in groups with and without suture respectively; P = 0·002). There were no differences in the perioperative and postoperative need for analgesics, postoperative wound complications or cervical scar cosmesis 6 months after surgery (mean(s.d.) POSAS 23·99(9·53) versus 26·51(8·69); P = 0·148).

Conclusion

Omitting the platysma muscle suture after thyroid surgery resulted in less wound-specific pain initially, with no difference in postoperative wound complications or cosmetic results. Registration number: NCT02951000 (http://www.clinicaltrials.gov).

No augmentation of indoleamine 2,3-dioxygenase (IDO) activity through belatacept treatment in liver transplant recipients

Belatacept is a second-generation cytotoxic T lymphocyte antigen (CTLA)-4 immunoglobulin (Ig) fusion protein approved for immunosuppression in renal transplant recipients. It was designed intentionally to interrupt co-stimulation via CD28 by binding to its ligands B7·1 and B7·2. Experimental evidence suggests a potential additional mechanism for CTLA-4 Ig compounds through binding to B7 molecules expressed on antigen-presenting cells (APCs) and up-regulation of indoleamine 2,3-dioxygenase (IDO), an immunomodulating enzyme that catalyzes the degradation of tryptophan to kynurenine and that down-regulates T cell immunity. So far it remains unknown whether belatacept up-regulates IDO in transplant recipients. We therefore investigated whether belatacept therapy enhances IDO activity in liver transplant recipients enrolled in a multi-centre, investigator-initiated substudy of the Phase II trial of belatacept in liver transplantation (IM103-045). Tryptophan and kynurenine serum levels were measured during the first 6 weeks post-transplant in liver transplant patients randomized to receive either belatacept or tacrolimus-based immunosuppression. There was no significant difference in IDO activity, as indicated by the kynurenine/tryptophan ratio, between belatacept and tacrolimus-treated patients in per-protocol and in intent-to-treat analyses. Moreover, no evidence was found that belatacept affects IDO in human dendritic cells (DC) in vitro. These data provide evidence that belatacept is not associated with detectable IDO induction in the clinical transplant setting compared to tacrolimus-treated patients.

Compliance of Clinical Pathways in Elective Laparoscopic Cholecystectomy: Evaluation of Different Implementation Methods

BACKGROUND

Clinical pathways aim to standardize perioperative and postoperative care of surgical procedures and are shown to result in a significant optimization associated with cost reduction. The aim of this study was to establish the impact of two different implementations forms of clinical pathways on the pathway compliance and resulting costs.

METHODS

Data of patients undergoing elective cholecystectomy for symptomatic cholecystolithiasis were collected over two different periods: using a clinical pathway in the form of a paper-based checklist, or a clinical pathway integrated into the paper-based medical treatment and nursing documentation. Outcome measures were compliance of the clinical pathway and total costs per case.

RESULTS

The compliance was significantly higher using integrated pathways compared to paper-based checklists (n = 117 of 123, 95 % vs 54 of 118, 46 %; p < 0.001). Mean total costs (€2206 vs €2458, p = 0.027) and length of hospital stay (2.13 vs 2.77 days, p < 0.001) were significantly reduced by the integrated clinical pathway compared to checklists. Further, the variation of costs per case and variation of length of hospital stay were significantly smaller with integrated clinical pathway (±€440 vs ±€538, p = 0.039 and ±0.53 vs ±0.68 days, p < 0.001, respectively). No difference regarding postoperative complication was observed (n = 3 vs. 4 events; p = 0.67).

CONCLUSION

Integrated clinical pathways display a significant higher compliance compared to checklists resulting in reduced total costs, shorter hospital stay and a smaller variation of cost, making it a useful tool in process controlling and planning.

Abdominal Wall Morbidity Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

Incisional hernia formation has been reported as high as 20% within 1 year following midline laparotomy. Since hyperthermic intraperitoneal chemotherapy is likely to impair wound healing, we sought to investigate the incidence of incisional hernia formation and abdominal wall rupture following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

METHODS

Consecutive patients with radiographic evidence of peritoneal metastases were scheduled for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy at the Comprehensive Cancer Center, University Hospital Tuebingen, Germany. Clinical data were retrospectively analyzed.

RESULTS

Between May 2005 and May 2014, 271 patients underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Within follow-up, 19 (7%) incisional hernias and 11 (4%) abdominal wall ruptures were observed. Age ⩾70 years, cardio-pulmonary comorbidity, the presence of pseudomyxoma peritonei or mesothelioma, and postoperative abdominal wall rupture were detected as risk factors for hernia formation. However, Cox multivariate analysis only confirmed the presence of pseudomyxoma peritonei or mesothelioma and postoperative abdominal wall rupture as independent risk factors.

CONCLUSION

Our data do not suggest that cytoreductive surgery and hyperthermic intraperitoneal chemotherapy is necessarily associated with a higher incidence of incisional hernia formation. However, patients suffering from pseudomyxoma peritonei or mesothelioma and patients with postoperative abdominal wall rupture seem to be at risk for developing incisional herniation.

Abstract A043: Discovery to first-in-man studies of a multi-peptide-based hepatocellular carcinoma vaccine adjuvanted with CV8102 (RNAdjuvant®): HEPAVAC

Hepatocellular (HCC)/normal adjacent tissue matched samples have been collected for HLA immunopeptidome analysis. 17 HCC samples from HLA-A*02+ patients and 15 samples from HLA-A*24+ patients have been analysed by mass spectrometry (LC-MS/MS). RNA-expression profiles have been established for 12 HCC samples. HLA-presentation/expression of peptides on primary HCC samples (as well as mRNA expression) were compared to normal tissue samples from relevant organs (including heart, brain, lung, kidney, liver, nerve, skin etc.) present in the Immatics' database. A total of 16 peptides have been selected and confirmed for immunogenicity for the HepaVac vaccine and are currently synthesized according to GMP standard. Of these, 7 are restricted to HLA-A*02; 5 to HLA-A*24 and 4 to HLA class II. Formulation development studies have been undertaken leading to a suitable and stable pharmaceutical form. An analytical method was developed which allows the characterization of each individual peptide within the HepaVac vaccine (IMA970A). At present, preclinical studies assessing the combination of the immunological RNA-based adjuvant (RNAdjuvant®) with the peptide-based HepaVac vaccine IMA970 are conducted. A single-arm, first-in-man trial entitled HepaVac-101 is designed to investigate in patients with very early, early and intermediate stage of HCC the off-the-shelf multi-peptide-based HCC vaccine (IMA970) plus the CV8102 adjuvant (RNAdjuvant®) following a single pre-vaccination infusion of low-dose cyclophosphamide acting as an immunomodulator. The study drugs are applied without concomitant anti-tumor therapy with the intention to reduce risk of tumor recurrence/progression in patients who have received all indicated standard treatments. The primary endpoints are safety, tolerability, and immunogenicity. Secondary/exploratory endpoints are additional immunological parameters in blood (e.g. regulatory T-cells, myeloid-derived suppressor cells, impact of the standard therapy on the natural immune response), infiltrating T-lymphocytes in tumor tissue, biomarkers in blood and tissue, disease-free survival/progression-free survival and overall survival. Once safety of this vaccination approach has been determined in the first 10-20 patients the addition of a checkpoint inhibitor will be considered. Suitable patients enrolled in Tuebingen are invited to participate in a trial extension investigating an actively personalized vaccine (APVAC) plus CV8102. The HepaVac project started in September 2013 and is supported by the European Commission's 7th Framework Program under the Grant Agreement Nr. 602893 (www.hepavac.eu). The clinical trial HepaVac-101 will be conduct in 6 centers located in 5 European countries, i.e. Italy (Naples and Varese), Germany (Tübingen), UK (Birmingham), Spain (Pamplona) and Belgium (Antwerpen).

Citation Format: Andrea Mayer-Mokler, Roberto Accolla, Yuk T. Ma, Regina Heidenreich, Francesco Izzo, Alfred Koenigsrainer, Markus Loeffler, Christian Flohr, Phillip Mueller, Sarah Kutscher, Hans-Georg Rammensee, Bruno Sangro, Sven Francque, Danila Valmori, Toni Weinschenk, Carsten Reinhardt, Ulrike Gnad-Vogt, Harpreet Singh, Luigi Buonaguro. Discovery to first-in-man studies of a multi-peptide-based hepatocellular carcinoma vaccine adjuvanted with CV8102 (RNAdjuvant®): HEPAVAC [abstract]. In: Proceedings of the Second CRI-CIMT-EATI-AACR International Cancer Immunotherapy Conference: Translating Science into Survival; 2016 Sept 25-28; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2016;4(11 Suppl):Abstract nr A043.

Anorectal malignant melanoma: curative abdominoperineal resection: patient selection with 18F-FDG-PET/CT

Background

Anorectal malignant melanomas (ARMM) are rare tumors, characterized by an early lymphatic spread and distant metastasis, resulting in an extremely poor overall survival. The objective of this study was to determine the pattern of regional lymph node metastasis (LNM) by computed tomography (CT) and 18F-FDG-PET/CT in patients undergoing abdominoperineal resection (APR) and its impact on oncologic outcome.

Methods

A retrospective analysis of six consecutive patients who underwent APR due to primary ARMM was performed. Patients were staged by CT and PET/CT.

Results

Four out of six patients had preoperative LNM involvement (two patients inguinal and perirectal, one iliacal, one perirectal), with two of them presenting with distant metastases additionally. Inguinal/iliacal LNM in two patients as well as liver metastasis in one patient was seen in PET/CT and missed by CT. The three patients with initial inguinal/iliacal LNM died during the observation period (overall survival: 10 (6–18) months). The three patients without inguinal/iliacal LNM involvement are currently alive, one patient showing a slowly progressive disease since 5 years, and two patients are tumor-free since 8.5 and 1.5 years (the patients had initial perirectal LNM).

Conclusions

In ARMM, PET/CT is superior to CT in detection of LNM and distant metastasis. APR is possibly a curative approach if the PET/CT shows exclusively perirectal LNM despite locally advanced tumor growth.

Abstract A115: Cancer vaccine development for hepatocellular carcinoma – HEPAVAC

The HEPAVAC Consortium aims to develop a highly innovative, novel cancer vaccine approach for hepatocellular carcinoma (HCC). The international project consortium consists of 9 European Partners from academia and the biotech industry with complementary and substantial expertise in developing immunotherapeutic strategies to treat cancer. The project has started in September 2013 and is supported by the European Commission's 7th Framework Program (www.hepavac.eu).

HCC/normal adjacent tissue matched samples have been collected for HLA immunopeptidome analysis. 17 HCC samples from HLA-A*02+ patients and 15 samples from HLA-A*24+ patients have been analysed by mass spectrometry (LC-MS/MS). RNA-expression profiles have been established for 12 HCC samples. HLA-presentation/expression of peptides and mRNA on primary HCC samples are compared to n&gt;140 normal tissue samples from relevant organs (including heart, brain, lung, kidney, liver, nerve, skin etc.) from Immatics' database.

A total of 9051 HLA-A*02-restricted different tumor-associated peptides (TUMAPs) have been identified from HLA-A*02+ samples, while a total of 3286 different HLA-A*24-restricted TUMAPs have been identified from HLA-A*24+ samples. Of these, 33 HLA-A*02+ TUMAPS and 33 HLA-A*24+ TUMAPs are currently in the process of validation, including peptide synthesis, immunogenicity testing and pharmaceutical evaluation. Most promising TUMAP candidates show selective expression only in HCC samples and no expression in normal tissues. In parallel, more than 6600 HLA-DR TUMAPs have been identified in Hep3B cells transfected with CIITA as well as an average of 1500 HLA-DR TUMAPs have been identified in HCC samples. Additional HLA-DR TUMAPs derived by distinct CIITA-transfected cell lines with different HLA-DR haplotypes are under scrutiny.

The discovery phase of the HEPAVAC project is proceeding according to the proposed timelines. HCC-specific epitopes to be included in the vaccine cocktail will be selected in the coming weeks for GMP production. In parallel, preclinical studies assessing the formulation and combination of the immunological RNA-based adjuvant (RNAdjuvant®) with peptide cocktails are underway.

Citation Format: Luigi Buonaguro, Sarah Kutscher, Roberto Accolla, Yuk T. Ma, Regina Heidenreich, Francesco Izzo, Alfred Koenigsrainer, Markus Loeffler, Phillip Mueller, Andrea Mayer, Hans-Georg Rammensee, Bruno Sangro, Sven Francque, Danila Valmori, Toni Weinschenk, Harpreet Singh-Jasuja. Cancer vaccine development for hepatocellular carcinoma – HEPAVAC. [abstract]. In: Proceedings of the CRI-CIMT-EATI-AACR Inaugural International Cancer Immunotherapy Conference: Translating Science into Survival; September 16-19, 2015; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2016;4(1 Suppl):Abstract nr A115.

Rapid thyroid nodule growth is not a marker for well-differentiated thyroid cancer

Background

Rapid growth of thyroid nodules is described as being associated with thyroid cancer. The objective of the study was to determine how the growth rate of thyroid nodules during follow-up is associated with the risk of thyroid cancer.

Methods

Retrospective analysis of patients undergoing thyroid surgery for nodular disease and a repetitive preoperative ultrasound work-up of at least 6 months was done. Nodule growth was considered relevant when a volume increase >49 % was detected. Growth patterns were described as rapid for a volume increase present over 6 to 24 months.

Results

Of the 297 analysed patients, 226 (76 %) displayed relevant nodule growth and 71 (24 %) no relevant growth. A rapid growth pattern was seen in 73 patients (32 %). Well-differentiated thyroid cancer was diagnosed in 33 patients (11 %; 27 papillary, 6 follicular) with a relevant nodule growth in 2 and no relevant growth in 31 patients. No rapid growth pattern was observed in any case of well-differentiated thyroid cancer. A rapid growth pattern occurred only in benign nodules (70 patients) and in 1 patient each with a lymphoma, a metastasis of a renal cell cancer and a metastasis of a gastric adenocarcinoma. Therapy with levothyroxine and/or iodine was administered to 129 patients (43 %) and was significantly inversely correlated with nodule growth (odds ratio 0.27; CI 95 % 0.14–0.53, p < 0.001).

Conclusions

Thyroid nodule growth alone and especially a rapid growth pattern during follow-up for thyroid nodular disease is not a marker for well-differentiated thyroid cancer and should not be used as a stand-alone argument for thyroid surgery.

Assessment of relapse in patients with peritoneal carcinomatosis after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy using F-18-FDG-PET/CT

PURPOSE

In patients with peritoneal carcinomatosis (PC), cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is an evolving therapeutic approach with curative intention. The differentiation between posttherapeutic findings after HIPEC and relapse of PC is challenging. We evaluated the diagnostic value of F-18-FDG-PET/CT in patients with relapse of PC after HIPEC.

MATERIALS AND METHODS

36 patients with recurring PC after HIPEC were examined on a whole-body PET/CT system (44 examinations). The examination included 3 D F-18-FDG-PET and contrast-enhanced CT. Images were assessed by two experienced readers regarding the presence and the extent of PC using the peritoneal carcinomatosis index (PCI). Imaging results were correlated with surgical findings or follow-up.

RESULTS

Relapse was suspected in 40 of 44 examinations. Relapse was missed by F-18-FDG PET/CT in 4 patients and significantly underestimated in 8 patients. The diagnostic accuracy for the detection of PC on a patient basis was 91 %, the sensitivity was 91 % and the positive predictive value was 100 %. The mean PCI was 11.4 ± 11.9 for PET/CT, 8.4 ± 10.3 for CT and 16.6 ± 15.0 in the case of surgical exploration. The extent of PC was underestimated by PET/CT and even more by CT alone (p < 0.05).

CONCLUSION

The diagnostic value of F-18-FDG PET/CT after cytoreductive surgery and HIPEC in the detection of recurring PC is superior to contrast-enhanced CT. However, the quantification of the extent of PC is limited due to post-therapeutic tissue alterations.

KEY POINTS

• Imaging of recurrent PC after HIPEC is challenging due to posttherapeutic tissue alterations.• The extent of recurrent PC after HIPEC is systematically underestimated by F-18-FDG PET/CT.• F-18-FDG PET/CT provides improved sensitivity for recurrent PC compared to contrast-enhanced CT.• The correlation of the extent of recurrent PC depicted by F-18-FDG PET/CT and surgical exploration is better than that of contrast-enhanced CT and surgical exploration.

Correlation of preoperative magnetic resonance imaging of peritoneal carcinomatosis and clinical outcome after peritonectomy and HIPEC after 3 years of follow-up: preliminary results

Purpose: In patients with peritoneal carcinomatosis, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is an evolving approach with curative intention. Previous studies indicate a correlation between preoperative magnetic resonance imaging (MRI) and surgical findings regarding the extent of peritoneal carcinomatosis. The aim of this study was to assess retrospectively whether preoperative MRI can predict the outcome and is therefore a suitable tool for patient selection. Materials and methods: Fifteen patients with laparoscopically proven peritoneal carcinomatosis were preoperatively examined using a 1.5-T whole-body MRI system. Results were correlated with surgical exploration. Follow-up was done by contrast-enhanced abdominal computed tomography and, if suspicious for recurring disease, laparoscopy or laparotomy. Survival time and interval to recurring disease were correlated with the preoperative peritoneal carcinomatosis index (PCI) on MRI (Spearman’s rank correlation). Results: In five patients radical resection could not be achieved (PCI 34 ± 6.9); survival time was 78.2 ± 54.1 days. In seven patients recurring disease was found 430 ± 261.2 days after initial complete cytoreduction (PCI 11.6 ± 6.9); survival time was 765.9 ± 355 days. Two patients are still alive after 3 years. Two patients with initially complete cytoreduction are without recurring disease after 3 years (PCI 5 and 12). One patient was lost for follow-up. Conclusions: Results of the preoperative MRI correlate well with the surgical PCI, postoperative resection status, and survival time. MRI might be a suitable technique for patient selection when considering peritonectomy and HIPEC. In our patients the outcome seems to correlate well with the extent of peritoneal carcinomatosis found by the preoperative MRI.

Phase I/II clinical trial of a genetically modified and oncolytic vaccinia virus GL-ONC1 in patients with unresactable, chemotherapy-resistant peritoneal carcinomatosis

3098

Background: For therapy-resistant peritoneal carcinomatosis (PC) viruses exhibiting oncolytic properties open up new perspectives. Our phase I/II study in patients with refractory PC (NCT01443260) is designed to assess the safety, MTD, and anti-tumor activity of GL-ONC1, a recombinant vaccinia virus (VACV) genetically engineered to selectively replicate in and destroy cancer cells. Methods: GL-ONC1 was administered intraperitoneally up to 4 times every 28 days under a standard 3+3 dose escalation design. Safety was assessed using CTCAEv4.0. Anti-tumor activity was determined by “fluid biopsies” obtained via repetitive paracenteses and by serial PET-CT scans. Patient samples were collected for pharmacokinetics, pharmacodynamics and viral shedding analysis. Results: Up to now, 4 patients have received 10 doses of GL-ONC1 ranging from 107 to 108 infectious viral particles per application.Adverse events have generally been limited to grade 1/2, being mostly transient flu-like symptoms as well as increased abdominal pain resulting from treatment-induced peritonitis. No DLT was reported. No viral shedding was observed. In one gastric cancer patient, effective intraperitoneal replication of GL-ONC1 was demonstrated for more than 3 weeks. Using either anti-EpCAM or anti-VACV specific antibodies, around 5% of all ascitic cells were found to be EpCAM-positive 3 days after treatment in this patient, and only around 5-10% of these cancer cells were VACV positive at the same time point. In contrast, 4 days later (i.e. 7 days after virotherapeutic treatment), less than 2% of all ascitic cells were still EpCAM-positive, and more than 90% of these cancer cells were VACV positive. Of note, VACV-positive cancer cells morphologically showed significant degenerative changes. Conclusions: Preliminary data demonstrate that GL-ONC1 is well tolerated when infused intraperitoneally. Importantly, a single intraperitoneal delivery of GL-ONC1 was found to be sufficient to cause a dramatic decline in the number of malignant cells in the ascitic fluid, suggesting that GL-ONC1 effectively removes tumor cells in the ascites of patients with PC. Clinical trial information: NCT01443260.

Spontaneous hepatic rupture in amyloidosis - report of a case

In systemic amyloidosis spontaneous rupture of the liver is a rare complication. Here we report on a patient with unrecognized systemic amyloidosis who presented to an outside hospital with unspecific abdominal pain. Under the signs of a hemorrhagic shock, distended abdomen and intraabdominal bleeding a laparotomy was performed. Due to uncontrollable hemorrhage of the ruptured right liver lobe a packing was performed. After being transferred to the reporting institution a CT scan was performed showing a grade IV laceration of the right liver. Therefore a transarterial embolization of the right hepatic artery was carried out. The following day an infection of the abdominal cavity and the abdominal wall with gas-producing bacteria was noticed and a relaparotomy, necrectomy and repacking due to diffuse bleeding were performed. The situation deteriorated and at the second relaparotomy the following day an almost completely necrotic liver was found. The patient deceased the following day. Life-threatening spontaneous liver rupture due to systemic amyloidosis might only successfully be cured by high urgency liver transplantation as presented in the literature. However, in two published cases interventional therapy by embolization of bleeding vessels has saved patients' life.

Prophylactic eculizumab prior to kidney transplantation for atypical hemolytic uremic syndrome

Atypical hemolytic uremic syndrome (aHUS) in childhood is a rare disease associated with high morbidity and mortality. Most cases progress to end-stage renal failure. In approximately 50% of affected patients, mutations in genes encoding complement proteins are causative of the impairment in the regulation of the complement alternative pathway. This leads to deficient host cell protection and inappropriate complement activation on platelets and endothelial cells, particularly in the kidneys. Complement factor H (FH) heterozygosity induces unregulated activation of the membrane attack complex (MAC) C5b-9. Present therapeutic strategies for aHUS include lifelong plasmapheresis and renal dialysis. Unfortunately, kidney transplantation is frequently an unsatisfactory intervention due to the high rate of post-transplantation HUS recurrence, particularly in patients with FH mutation. Combined liver-kidney transplantation is also associated with poor outcome, mostly as a result of premature liver failure secondary to uncontrolled complement activation. Eculizumab is a complement C5 antibody that inhibits complement factor 5a (C5a) and the formation of the MAC. Thus, this antibody may be a promising new agent for patients with an aHUS undergoing kidney transplantation. We present the first case of a young patient with aHUS who received eculizumab as prophylactic treatment prior to a successful kidney transplantation.

Cytomegalovirus reactivation and associated outcome of critically ill patients with severe sepsis

INTRODUCTION

Sepsis has been identified as a risk factor for human cytomegalovirus (CMV) reactivation in critically ill patients. However, the contribution of CMV reactivation on morbidity and mortality is still controversial. Therefore, we analyzed the incidence and impact of CMV reactivation on outcome in patients with severe sepsis.

METHODS

In a prospective longitudinal double-blinded observational study, 97 adult nonimmunosuppressed CMV-seropositive patients with new onset of severe sepsis were included. Leukocytes, plasma and tracheal secretions were examined weekly for CMV-DNA by PCR. Tracheal secretions were additionally tested for HSV (Herpes Simplex Virus)-DNA. The influence of CMV-reactivation on the endpoints was analysed by Cox proportional-hazard regression analysis. Time-dependency was evaluated by landmark analysis.

RESULTS

Six out 97 died and five were discharged from the hospital within 72 hours and were excluded of the analysis. CMV reactivation occurred in 35 of the 86 (40.69%) analysed patients. HSV infection occurred in 23 of the 35 (65.7%) CMV reactivators. In 10 patients CMV-plasma-DNAemia appeared with a DNA-content below 600 copies/ml in four cases and a peak amount of 2,830 copies/ml on average. In patients with and without CMV reactivation mortality rates were similar (37.1% vs. 35.3%, P = 0.861), respectively. However, in the multivariate COX regression analyses CMV reactivation was independently associated with increased length of stay in the ICU (30.0, interquartile range 14 to 48 vs. 12.0, interquartile range 7 to 19 days; HR (hazard ratio) 3.365; 95% CI (confidence interval) 1.233 to 9.183, P = 0.018) and in the hospital (33.0, interquartile range 24 to 62 vs. 16.0, interquartile range 10 to 24 days, HR 3.3, 95% CI 1.78 to 6.25, P < 0.001) as well as prolonged mechanical ventilation (22.0, interquartile range 6 to 36 vs. 7.5, interquartile range 5 to 15.5 days; HR 2.6,CI 95% 1.39 to 4.94; P < 0.001) and impaired pulmonary gas exchange (six days, interquartile range 1 to 17, vs. three, interquartile range 1 to 7, days in reactivators vs. non-reactivators, P = 0.038). HSV reactivation proved not to be a risk factor for these adverse effects.

CONCLUSIONS

These data indicate an independent correlation between CMV reactivation and increased morbidity in the well-defined group of nonimmunosuppressed patients with severe sepsis, but CMV reactivation had no impact on mortality in this group with low CMV-DNA plasma levels. Thus, the potential harms and benefits of antiviral treatment have to be weighed cautiously in patients with severe sepsis or septic shock.

Effect of changes in the glycolytic metabolism on tumor progression and dissemination in gastric cancer

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Background: Metastases are a frequent finding in gastric cancer patients and are associated with a poor prognosis. Recent data indicate that there might be a link between metabolic changes in the glycolytic system and dissemination in gastric cancer. The enhanced expression of the glycolytic enzyme phosphoglycerate kinase 1 (PGK1) and its signalling targets CXCR4 and CXCL12 seem to play a crucial role in enabling gastric tumours to develop dissemination.

Methods: Microarray analysis was conducted investigating human specimens from consecutive gastric cancer patients with dissemination versus gastric cancer patients without dissemination. Subsequently siRNA-knock- down concerning PGK1 and CXCR4 and transfection (overexpression) of PGK1 was performed. Further, our thesis was investigated in a metastatic nude mouse model simulating human gastric cancer behavior by orthotopic tumour implantation. Tumour growth was detected by PET-MR-imaging and section of the animals.

Results: Microarray analysis revealed a significant overexpression of PGK1, CXCR4 and CXCL12 in gastric cancer specimens with dissemination. Further siRNA-knock-down of PGK1 and CXCR4 showed a significant co-regulation on expression and protein level in vitro. The transfection (overexpression) of PGK1 also revealed a significant upregulation of its signalling targets CXCR4 and CXCL12 on expression and protein level. In addition the transfected cells showed a 50-fold distinctive property in the invasion assay compared to cancer cells without PGK1 overexpression. The in-vivo results obtained in the mouse model showed that elevated PGK1 expression increased invasive and metastatic behavior of implanted gastric tumours significantly and PET-MR-imaging and section correlated very well comparing tumour growth and metastasis.

Conclusions: The overexpression of the glycolytic enzyme PGK1 and its signalling targets in gastric cancer might be a promising regulation-pathway promoting dissemination. This data may provide new prognostic markers and/or potential therapeutic targets to prevent migration of gastric carcinoma cells and has intriguing connection to an old hypothesis advocated by Otto Warburg for tumour metabolism.

No significant financial relationships to disclose.

Circadian expression of clock- and tumor suppressor genes in human oral mucosa

PURPOSE

Circadian rhythms are daily oscillations of multiple biological processes driven by endogenous clocks. Imbalance of these rhythms has been associated with cancerogenesis in humans. To further elucidate the role circadian clocks have in cellular growth control, tumor suppression and cancer treatment, it is revealing to know how clock genes and clock-controlled genes are regulated in healthy humans.

MATERIALS AND METHODS

Therefore comparative microarray analyses were conducted investigating the relative mRNA expression of clock genes throughout a 24-hour period in cell samples obtained from oral mucosa of eight healthy diurnally active male study participants. Differentially expressed selected genes of interest were additionally evaluated using qRT-PCR.

RESULTS

Microarray analysis revealed 33 significant differentially regulated clock genes and clock- controlled genes, throughout a one day period (6.00h, 12.00h, 18.00h, 24.00h). Hereof were 16 clock genes and 17 clock- controlled genes including tumor suppressor- and oncogenes. qRT-PCR of selected genes of interest, such as hPER2, hCRY1, hBMAL1, hCCRN4L and hSMAD5 revealed significant circadian regulations.

CONCLUSION

Our study revealed a proper circadian regulation profile of several clock- and tumor suppressor genes at defined points in time in the participants studied. These findings could provide important information regarding genes displaying the same expression profile in the gastrointestinal tract amounting to a physiological expression profile of healthy humans. In the future asynchronous regulations of those genes might be an additional assistant method to detect derivations distinguishing normal from malignant tissue or assessing risk factors for cancer.

Standardized intensive care unit management in an anhepatic pig model: new standards for analyzing liver support systems

Introduction

Several anhepatic pig models were developed in the past. Most models suffer from short anhepatic survival times due to insufficient postoperative intensive care unit (ICU) management. The aim of this study was to analyze anhepatic survival time under standardized intensive care therapy in a pig model.

Methods

Eight pigs underwent total hepatectomy after Y-graft interposition between the infrahepatic vena cava and the portal vein to the suprahepatic vena cava. An intracranial probe was inserted for intracranial pressure (ICP) monitoring. Animals received pressure-controlled ventilation under deep narcosis. Vital parameters were continuously recorded. Urinary output, blood gas analysis, haemoglobin, hematocrit, serum electrolytes, lactate, and glucose were monitored hourly, and creatinine, prothrombin time, international normalised ratio, and serum albumin were monitored every 8 hours. Sodium chloride solution 0.9%, hydroxyethyl starch 6%, fresh frozen plasma, and erythrocyte units were used for volume substitution, and norepinephrine was used to prevent severe hypotension. Serum electrolytes and acid-base balance were corrected as required. Antibiotic prophylaxis with ceftriaxon was given daily, as well as furosemide, to maintain diuresis.

Results

Postoperative survival was 100% after 24 hours, with a maximum survival of 73 (mean, 58 ± 4) hours. Haemodynamic parameters such as heart rate, mean arterial pressure, and pulse oximetry remained stable during surgical procedures and following anhepatic status due to ICU therapy until escalating at time of death. Deteriorating pulmonary function could be stabilized by increasing oxygen concentration, positive end-expiratory pressure, and maximal airway pressure. Furosemide was used to maintain diuresis until renal failure occurred. ICP started at 15-17 mmHg and increased continuously up to levels of 41-43 mmHg at time of death. All animals died as a result of multiple-organ failure.

Conclusions

Using standardized intensive care management after total hepatectomy, we were able to prolong anhepatic survival over 58 hours without the use of liver support systems. The survival benefit of liver support systems in previous animal studies should be reevaluated against our model.

Expansion and differentiation of neural progenitors derived from the human adult enteric nervous system

BACKGROUND & AIMS

Neural stem and progenitor cells from the enteric nervous system have been proposed for use in cell-based therapies against specific neurogastrointestinal disorders. Recently, enteric neural progenitors were generated from human neonatal and early postnatal (until 5 years after birth) gastrointestinal tract tissues. We investigated the proliferation and differentiation of enteric nervous system progenitors isolated from human adult gastrointestinal tract.

METHODS

Human enteric spheroids were generated from adult small and large intestine tissues and then expanded and differentiated, depending on the applied cell culture conditions. For implantation studies, spheres were grafted into fetal slice cultures and embryonic aganglionic hindgut explants from mice. Differentiating enteric neural progenitors were characterized by 5-bromo-2-deoxyuridine labeling, in situ hybridization, immunocytochemistry, quantitative real-time polymerase chain reaction, and electrophysiological studies.

RESULTS

The yield of human neurosphere-like bodies was increased by culture in conditional medium derived from fetal mouse enteric progenitors. We were able to generate proliferating enterospheres from adult human small or large intestine tissues; these enterospheres could be subcultured and maintained for several weeks in vitro. Spheroid-derived cells could be differentiated into a variety of neuronal subtypes and glial cells with characteristics of the enteric nervous system. Experiments involving implantation into organotypic intestinal cultures showed the differentiation capacity of neural progenitors in a 3-dimensional environment.

CONCLUSIONS

It is feasible to isolate and expand enteric progenitor cells from human adult tissue. These findings offer new strategies for enteric stem cell research and future cell-based therapies.

Intestinal lipid absorption increases cold ischemia of the small bowel in rats

The short cold ischemic tolerance of the gut is a major problem in small bowel transplantation. We have shown that intestinal lipid administration is beneficial during systemic inflammation like sepsis.

METHODS

Rats were intestinally infused with either water or 1% olive oil for 12 hours. The small bowel was removed and stored in HTK solution on ice. At t = 0, t = 60, t = 120, t = 180, t = 240, t = 300, t = 360, t = 420, and t = 480 minutes, a tissue sample of the gut was fixed, stained, and analyzed by three independent observers. Damage score was calculated (0 = no damage, 1 = minor damage, 2 = major damage, 3 = loss of structure) for integrity of the mucosa, integrity of the basal membrane of the mucosa, and integrity of villy. The damage score was allocated when all three observers agreed on the same or a higher damage score.

RESULTS

In all control animals minor damage for the integrity of the basal membrane occurred within 60 minutes, but in only 50% of the lipid-treated rats. In all control rats, major damage for both integrity of mucosa and villi occurred within 300 minutes or less, but only in 50% of the lipid-treated rats. In all control rats, the structure of the villi was completely lost within 480 minutes or less, whereas only 50% of the lipid treated animals reached maximal damage scores for either mucosa or villi.

CONCLUSION

Intestinal lipid administration before cold storage clearly decreases histologic damage of the small bowel and might increase the tolerance for cold ischemia. Lipids or their metabolites stored in enterocytes may act as an antiinflammatory. Intestinal lipid administration in organ donors might be useful to increase cold ischemic tolerance of the small bowel.

Postoperative complications have little influence on long-term quality of life in Crohn's patients

PURPOSE

The purpose of the study was to determine the influence of postoperative complications on long-term quality of life in patients after abdominal operations for Crohn's disease.

MATERIALS AND METHODS

From 1996 to 2002, 305 Crohn's patients underwent abdominal surgery, and 66 patients developed postoperative complications. Quality of life was studied using a standardized questionnaire and four quality of life instruments. Sixty-six Crohn's patients with uneventful postoperative course matched for age, and follow-up time served as controls.

RESULTS

Forty-eight patients (81%) in the complication group (32 major and 16 minor) and 43 patients (75%) in the control group answered the questionnaire. Postoperative follow-up time was 42 (10-94) and 41 months (13-94; median (range)). Quality of life was comparable between groups, except on the subscale "physical functioning" of the Short-form 36 on which patients with minor and major complications showed impaired quality of life compared to controls (67+/-6, 69+/-4, and 84+/-2%; mean+/-standard error of the mean; both p<0.05 vs controls). The incidence of Crohn's disease-related symptoms at follow-up was unaffected by complications (minor 63%, major 56% vs controls 70%; both not significant).

CONCLUSION

Postoperative complications after abdominal operations for Crohn's disease do not impair long-term quality of life in general but may affect specific dimensions of quality of life like patients' physical function.

Successful coil embolization of a ruptured gastroduodenal artery aneurysm

Aneurysms of the gastroduodenal artery are rare. Reported here is the case of a 60-year-old woman suffering from the covered rupturing of a twin aneurysm of the gastroduodenal artery. The patient presented herself in the surgical emergency unit with abdominal discomfort. Diagnostics showed free fluid in the abdominal cavity together with anemia of 9.9 g/dL. A computed tomography scan and an angiography revealed the covered rupturing of a twin aneurysm of the gastroduodenal artery, which was treated by endovascular coiling of the gastroduodenal and pancreaticoduodenal arteries. The patient's hemoglobin level remained stable after treatment, and she was released from the hospital after 18 days. Visceral artery aneurysms are rare. Although endovascular therapy is preferred in cases involving active bleeding, surgery remains the primary therapy in those cases in which bleeding becomes uncontrollable.

Long-term quality of life in patients with Crohn's disease and perianal fistulas: influence of fecal diversion

PURPOSE

Symptomatic perianal fistulas impair quality of life in patients with Crohn's disease. Fecal diversion improves symptoms but may impair quality of life. This study was designed to compare long-term quality of life in patients with Crohn's disease with symptomatic perianal fistulas who were treated with or without fecal diversion.

METHODS

From 1996 to 2002, perianal fistulas were treated in 116 patients with Crohn's disease. A questionnaire, including four quality of life instruments, was mailed to each patient (Short-Form General Health Survey, Gastrointestinal Quality of Life Index, Cleveland Global Quality of Life Score, Short Inflammatory Bowel Disease Questionnaire).

RESULTS

Questionnaires were returned by 77 of 116 patients (66 percent). Thirty-four of these patients had undergone fecal diversion, whereas 43 had not. Median follow-up was 49 (range, 18-97) months in diverted and 44 (range, 14-98) months in undiverted patients (not significant). In the diverted group, 44 percent complained of Crohn's disease-related symptoms, which was less compared with 79 percent in undiverted patients (P < 0.05). Diverted patients achieved 68 +/- 1 percent of the maximum possible score on the Gastrointestinal Quality of Life Index compared with 60 +/- 2 percent in undiverted patients (mean +/- standard error of the mean; P < 0.001); diverted patients scored better on the subscale "gastrointestinal symptoms" of the Gastrointestinal Quality of Life Index (81 +/- 1 percent vs. 67 +/- 2 percent; P < 0.001). There was no difference in the Short Inflammatory Bowel Disease Questionnaire between diverted and undiverted patients except for the subscale "bowel function" (91 +/- 2 percent vs. 76 +/- 2 percent; P < 0.0001). No difference in quality of life was detected by the Short-Form General Health Survey and Cleveland Global Quality of Life Score.

CONCLUSIONS

In the investigated population of patients with Crohn's disease, quality of life seems to be similar or potentially superior in diverted patients suffering from perianal fistulas compared with undiverted patients. A diverting stoma, therefore, may improve quality of life in patients with severe perianal Crohn's disease.

Sentinel lymph node biopsy in colon cancer: a prospective multicenter trial

INTRODUCTION

The clinical impact of sentinel lymph node biopsy (SLNB) in colon cancer is still controversial. The purpose of this prospective multicenter trial was to evaluate its clinical value to predict the nodal status and identify factors that influence these results.

METHODS

Colon cancer patients without prior colorectal surgery or irradiation were eligible. The sentinel lymph node (SLN) was identified intraoperatively by subserosal blue dye injection around the tumor. The SLN underwent step sections and immunohistochemistry (IHC), if classified free of metastases after routine hematoxylin and eosin examination.

RESULTS

At least one SLN (median, n = 2) was identified in 268 of 315 enrolled patients (detection rate, 85%). Center experience, lymphovascular invasion, body mass index (BMI), and learning curve were positively associated with the detection rate. The false-negative rate to identify pN+ patients by SLNB was 46% (38 of 82). BMI showed a significant association to the false-negative rate (P < 0.0001), the number of tumor-involved lymph nodes was inversely associated. If only slim patients (BMI < or =24) were investigated in experienced centers (>22 patients enrolled), the sensitivity increased to 88% (14 of 16). Moreover, 21% (30 of 141) of the patients, classified as pN0 by routine histopathology, revealed micrometastases or isolated tumor cells (MM/ITC) in the SLN.

CONCLUSIONS

The contribution of SLNB to conventional nodal staging of colon cancer patients is still unspecified. Technical problems have to be resolved before a definite conclusion can be drawn in this regard. However, SLNB identifies about one fourth of stage II patients to reveal MM/ITC in lymph nodes. Further studies must clarify the clinical impact of these findings in terms of prognosis and the indication of adjuvant therapy.

Radiation-induced sarcoma: A single center experience with 36 cases

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Background: Radiation-induced sarcoma (RIS) is a rare complication of radiation therapy for any cause. With increasing numbers of patients receiving radiotherapy, data concerning the incidence and treatment outcome of RIS are urgently needed. Methods: We screened our local sarcoma registry for patients with RIS. 36 cases of RIS that had developed after radiation for malignant disease were identified and analyzed retrospectively over a 12 year period (1994–2006). Results: All patients had received radiation therapy between 1968 and 2002. The most frequent primary tumors were breast cancer (n = 19) and lymphoma (including Hodgkin`s and non-Hodgkin`s lymphoma, n = 9). The remainder received radiation therapy for tumors of the female reproductive organs (n = 2), head and neck cancer (n = 4), neuroblastoma (n = 1), and seminoma (n = 1).The median of delivered total radiation dose per patient was 50 Gy (35 to 72 Gray). Sources of irradiation were photons (n = 9), cobalt (n = 6), electrons (n = 2), and unknown in 19 cases. The median time interval from the start of irradiation the detection of the sarcoma was 11 years (1 - 35 years). The tumors arose within the radiation field in 29 cases, on the border of the field in 6 cases, and out of field in 1 case. The histology of RIS was angiosarcoma in most cases (n = 12), followed by pleomorphic sarcomas (n = 11), leiomyosarcoma (n = 4), fibrosarcoma (n = 2), osteosarcoma (n = 2), and others (n =5). Most cases were detected in a localized stage of disease (n = 33), and therefore, complete surgical removal was achieved in almost 50% (n = 17). However, this did not translate into long term survival within the overall study population. Only 11 patients remain free of disease during a mean follow-up period of 29 months (range, 0 - 51). Conclusions: Angiosarcomas within or on the border of the radiation field are the most common histological subentity of RIS. Therefore, follow-up of previously irradiated patients should include examination of irradiated regions with a high level of suspicion if cutaneous atypical vascular lesions are found. However, the clinician should be aware of the fact that RIS also occurs out of field and can be of non-angiogenic subtype as well. As far as treatment is concerned, RIS is treated the same as non-radiation induced sarcoma.

No significant financial relationships to disclose.

Postoperative colonic motility after tropisetron and a standardized meal in patients undergoing conventional colorectal surgery

BACKGROUND

Early postoperative enteral nutrition is advantageous for the recovery of colonic motility but may be limited by abdominal distension, nausea, and vomiting. We aimed to investigate the tolerance of a standardized meal after pretreatment with the 5-hydroxytryptamine-3-receptor antagonist tropisetron and to study the concomitant colonic motility.

METHODS

Colonic motility and tone were recorded on postoperative day 1 to 3 with a combined manometry/barostat recording catheter in 12 patients who underwent open colorectal surgery with an anastomosis in the distal colon or rectum. The study protocol consisted of 30 min of baseline recordings followed by 5 mg of tropisetron intravenously. Then, motility was recorded for another 30 min before patients ingested a standardized meal to trigger the gastrocolonic response. Postprandial motility was recorded for the subsequent 60 min.

RESULTS

The colonic motility index increased after administration of tropisetron on all three postoperative days (day 1: 34+/-11 vs 122+/-48, day 2: 55+/-19 vs 101+/-25, and day 3: 42+/-16 vs 93+/-33 mmHg/min; p<0.05). No further increase of the motility index was observed postprandially. Frequency and amplitude of contractions were virtually unaffected by tropisetron and the meal. Barostat bag volume decreased postprandially in the proximal bag on the third, and in the distal bag on the first and second postoperative day (p<0.05). Patients' condition was unaffected by the standardized meal after tropisetron administration.

CONCLUSIONS

Tropisetron may enhance colonic motility in the early postoperative period; however, the gastrocolonic response was impaired thereafter. High caloric food intake is well tolerated early after surgery after tropisetron pretreatment.

Long-term outcome of endoscopic treatment of biliary strictures after liver transplantation

Biliary strictures are one of the most common complications following liver transplantation (LT), with an incidence of 5.8-34%. Endoscopic techniques have been successfully used to treat biliary complications; however, the long-term efficacy and safety of this treatment option has not yet been fully elucidated. This prospective study was performed to determine the efficacy and safety of endoscopic management of biliary complications after LT and its impact on long-term patient and graft survival. Biliary strictures were suspected in the presence of elevated liver parameters and/or abnormal abdominal sonography and subsequently diagnosed by endoscopic retrograde cholangiography (ERC). The mean follow-up was 39.8 (range, 0.3-98.2) months after first ERC. Between October 1992 and December 2003, a total of 515 patients underwent LT. Biliary complications were diagnosed in 84 patients (16.3 %). Anastomotic strictures (AS) alone were found in 65 (12.6%) and nonanastomotic strictures (NAS) in 19 patients (3.7%). Long-term success was observed in 77% of patients with AS. In patients with NAS, partial long-term responses could be achieved in 63% of patients. Five patients (6.2%) required a percutaneous and 6 (7.4%) patients a surgical approach. In conclusion, the long-term outcome for patients with post-liver transplant biliary strictures after endoscopic treatment is excellent, especially for patients with AS. Development of NAS reduces graft but not patient survival after endoscopic therapy.

Simultaneous pancreas-kidney transplantation in a large multicenter study: surgical complications

Simultaneous pancreas-kidney (SPK) transplantation has evolved as an effective treatment modality for patients with end-stage nephropathy owing to type 1 diabetes mellitus. This kidney-pancreas transplant procedure includes a number of risks, one of them being surgical complications, which were analyzed in this large prospective multicenter study.

PATIENTS AND METHODS

The analysis included 205 patients randomly assigned to tacrolimus (n = 103) or cyclosporine ME (n = 102) in the Euro-SPK001 study. Surgical complications were defined as any intervention in the postoperative course related to the transplant procedure.

RESULTS

The number of patients undergoing relaparotomy was significantly lower among the tacrolimus group (26.2%) as compared to the cyclosporine ME group (43.1%, P = .0109). Relaparotomy was performed earlier in the cyclosporine ME group (day 14 +/- 17) compared to patients in the tacrolimus group (day 26 +/- 26, P = .0506). Graft vessel thrombosis, intra-abdominal hemorrhage, and enteric or ureteral leakage within the first 3 months occurred significantly more frequently in cyclosporine ME-treated patients. Donor age above 45 years showed a negative impact on surgical complications. Relaparotomy had no impact on patient survival but significantly affected pancreas and kidney graft survival in both groups.

CONCLUSION

This prospective, randomized, multicenter trial in patients undergoing primary SPK demonstrated a benefit of tacrolimus over cyclosporine ME with regard to the incidence of surgical complications and, consecutively, to kidney and pancreas graft survival.

Alendronate in combination with calcium and vitamin D prevents bone loss after orthotopic liver transplantation: a prospective single-center study

Bone loss is a common complication in patients before and after liver transplantation (LT). The aim of this study was to investigate the efficacy of prophylactic treatment with bisphosphonates after LT in preventing progressive bone loss in LT patients. We included 136 patients with end-stage liver diseases awaiting LT. Bone mineral density (BMD) (by dual X-ray absorptiometry) and markers of bone metabolism were determined before, and 4, 12, 24, 36, and 48 months after LT. All patients received vitamin D and calcium supplementation before and after LT, those with osteopenia or osteoporosis prior to LT were additionally treated with alendronate following LT. Decreased BMD was seen in a high percentage of patients undergoing LT (osteopenia 48.5%, osteoporosis 23.5%). Reduced BMD before LT was not related to gender, underlying liver disease, or Child-Turcotte-Pugh classification. Body mass index (BMI) prior to LT, however, correlated significantly with the fracture risk. Alendronate prevented the ubiquitously observed bone loss after LT in patients with osteoporosis and osteopenia and, in addition, led to an increase in BMD in patients with osteoporosis within 24 months after LT. In conclusion, our study suggests that alendronate is efficacious in preventing the natural course of bone loss associated with LT.

Employing vasopressin as an adjunct vasopressor in uncontrolled traumatic hemorrhagic shock. Three cases and a brief analysis of the literature

Resuscitation of patients in hemorrhagic shock remains one of the most challenging aspects of trauma care. We showed in experimental studies that vasopressin, but not fluid resuscitation, enabled short-term and long-term survival in a porcine model of uncontrolled hemorrhagic shock after penetrating liver trauma. In this case report, we present two cases with temporarily successful cardiopulmonary resuscitation (CPR) using vasopressin and catecholamines in uncontrolled hemorrhagic shock with subsequent cardiac arrest that was refractory to catecholamines and fluid replacement. In a third patient, an infusion of vasopressin was started before cardiac arrest occurred; in this case, we were able to stabilize blood pressure thus allowing further therapy. The patient underwent multiple surgical procedures, developed multi-organ failure, but was finally discharged from the critical care unit without neurological damage.

Spectrum of surgical complications after simultaneous pancreas–kidney transplantation in a prospectively randomized study of two immunosuppressive protocols

BACKGROUND

Simultaneous pancreas-kidney transplantation (SPK) has evolved as an effective treatment for patients with end-stage nephropathy due to type 1 diabetes mellitus. This report analyses the spectrum of surgical complications among patients receiving tacrolimus and cyclosporin microemulsion (ME)-based therapy for SPK transplantation.

METHODS

The analysis included 205 patients randomly assigned to tacrolimus (n = 103) or cyclosporin-ME (n = 102) in the Euro-SPK 001 study. Surgical complications were defined as any intervention in the 3-month post-operative course related to the transplant procedure.

RESULTS

In the tacrolimus vs cyclosporin-ME group, repeat laparotomy was required by fewer patients (26 vs 43%, respectively; P = 0.01) and at a later stage post-transplant (26+/-26 vs 14+/-17 days; P = 0.05). Also, thrombosis of graft vessels (2 vs 9%; P = 0.03) and repeat laparotomy for intra-abdominal haemorrhage within the first 3 months (8 vs 22%; P = 0.005) occurred significantly less frequently with tacrolimus vs cyclosporin-ME. A donor age of > or =45 years was a significant determinant for surgical complications requiring repeat laparotomy, regardless of the type of immunosuppression. Portal anastomosis was the safest method of endocrine venous drainage, and Roux-en-Y loop for enteric exocrine drainage was associated with a higher re-operation rate than duodenoenterostomy. Repeat laparotomy had no impact on patient survival, but significantly reduced kidney and pancreas graft survival in the cyclosporin-ME group (kidney: P<0.01; pancreas: P<0.001) and in both groups combined (P < or = 0.05 and P<0.001, respectively).

CONCLUSIONS

The immunological benefits of tacrolimus compared with cyclosporin-ME treatment result in a lower incidence of repeat laparotomies post-transplant and a reduced in-hospital stay. Fewer repeat laparotomies translate into improved pancreas and kidney graft survival.

Infectious Complications Limit the Outcome of Liver Transplantation in Medical Urgency Code 2 Patients

The Organ shortage has caused an accumulation of acutely decompensated patients listed as medical urgency code 2 (MUC 2) (United network for Organ Sharing 2) while awaiting liver transplantation. Between June 1997 and June 2003, 22 of 360 liver transplantation patients (6%) were listed as MUC 2. Prophylactic immunosuppression consisted of calcineurin inhibitor-based drug therapy, using antithymocyte globulin or interleukin-2 receptor antagonist induction in 64%. The overall perioperative infection rate was 50%, and the rejection rate was 23%. We observed 7 episodes of oral or genital herpes simplex virus lesions; 2 patients (both with cytomegalovirus-mismatched transplants) developed cytomegalovirus disease, and another 5 patients received ganciclovir for preemptive therapy or prophylaxis. Two patients developed pneumonia: 5, sepsis that originated in 4 cases from a contaminated central venous line; and 1 methicillin-resistant endocarditis, which resulted in Staphylococcus aureus lethal outcome. After a median follow up of 3 years, 1 patient underwent a repeat transplantation procedure and 6 patients had died, 4 of them from infectious complications. Liver transplantation of MUC 2-listed patients may result in acceptable results similar to those of MUC 3 and MUC 4 categories.

Percutaneous Management of a Hepatic Artery Aneurysm: Bleeding After Liver Transplantation

In this article we present an unusual case of hepatic artery aneurysm bleeding due to a hepatic artery thrombosis after liver transplantation. The patient developed a recurrent hepatic artery thrombosis leading to severe graft failure in four consecutive liver transplantations. While being evaluated for a fifth transplant, stabilization of the clinical situation was attempted by interventional therapy. The first intervention was to place a stent into the hepatic artery to prevent further ischemic damage. This failed to improve graft function, but unfortunately led to the development of a pseudoaneurysm at the distal end with a subsequent rupture into the biliary tree. Bleeding was treated successfully by direct puncture and coil embolization of the aneurysm. In addition, the patient demonstrated a hemodynamically relevant portal vein stenosis on the CT scan. Stenting of the portal vein markedly improved graft function. After extensive investigations, a paroxysmal nocturnal hemoglobinuria was found to be the underlying cause of the recurrent hepatic artery thrombosis. Here we suggest that hepatic artery aneurysm bleeding is a rare but potentially fatal complication that can be successfully treated by percutaneous coil embolization. Additionally, we propose that stenting of the portal vein can lead to a significant improvement of the graft perfusion even though the hepatic artery remained occluded.