Cancer of the Appendix in Long-Standing Ulcerative Colitis: A Case Report

Cancer of the appendix was found in a 69-year-old female patient affected by long-standing ulcerative colitis (UC). On histological examination the cancer was a typical cystadenocarcinoma of the appendix. The appendiceal mucosa not invaded by the neoplastic process was normal. Histological examination of the colorectal mucosa did not show dysplasia or cancer. These findings suggest that appendiceal cancer and UC may be unrelated diseases. A surveillance program for early detection of cancer of the appendix in patients with longstanding UC does not seem mandatory.

Radiotherapy in the management of gist: state of the art and new potential scenarios

Background

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal neoplasm of the gastrointestinal tract. The main treatment for localized gastrointestinal stromal tumors is surgical resection. Unresectable or advanced GIST are poorly responsive to conventional cytotoxic chemotherapy but the introduction of tyrosine kinase inhibitors (TKIs) marked a revolutionary step in the treatment of these patients, radically improving prognosis and clinical benefit. Historically GIST has been considered radiation-resistant, and the role of radiotherapy in the management of patients with GIST is currently restricted to symptomatic palliation in current treatment guidelines.

Case presentation

Here we report two patients affected by metastatic GIST, treated with radiotherapy and radiosurgery in combination with TKIs, achieving an unexpected objective response in the first case and a significant clinical benefit associated with a local tumor control of several months in the second case.

Conclusions

These and other successful experiences that are progressively accumulating, open up new scenarios of use of radiation therapy in various settings of treatment. GIST is not universally radioresistant and radiotherapy, especially if combined with molecularly targeted therapy, can improve the outcomes for patients diagnosed with GIST.

Port-a-Cath-related complications in 252 patients with solid tissue tumours and the first report of heparin-induced delayed hypersensitivity after Port-a-Cath heparinisation

The use of the subcutaneous Port-a-Catheters (Port-a-Caths) provides an important mean of venous access for oncological patients. The aim of our retrospective consecutive single-centre study was to investigate Port-a-Cath-related complications in 252 cancer patients. Overall period of Port-a-Caths maintenance was 25 months. The strategy of our centre is to keep Port-a-Caths in situ up to the end of follow-up in adjuvant cancer patients. A total of 22 complications were recorded (8.73%). Interventional complications occurred in four patients. The main complications during Port-a-Cath use included thrombosis (4 patients, 1.58%), infections (4 patients, 1.58%), persistent pain or discomfort (3 patients, 1.19%) and dislocations (2 patients, 0.79%). Median time to the occurrence of any type of complications was 4.5 months. Eleven Port-a-Caths were removed due to complications (4.36%). Similar rate of Port-a-Cath-related thrombosis/infection was seen in adjuvant and advanced cancer patients (no statistical significance). Continuous infusion of anticancer therapy via a Port-a-Cath system is a relatively safe procedure, although major complications might occur. We are first to describe heparin-induced delayed hypersensitivity after heparinisation of Port-a-Cath. This fact should influence the preference to keep the Port-a-Cath after completion of adjuvant anticancer treatment.

Molecular detection of epidermal growth factor receptor in colorectal cancer: does it still make sense?

AIM

The aim of the study was to detect and compare the epidermal growth factor receptor (EGFr) content using different methods, to establish whether the quantitative detection and functional study of EGFr in colorectal cancer, using methods other than immunohistochemistry (IHC), are appropriate.

METHOD

Analysis of EGFr by IHC was performed in 230 colorectal cancer patients using monoclonal anti-EGFr. Total and activated EGFr (pY1068) contents were determined in 92 patients and real-time PCR, to determine the level of EGFr messenger RNA, was carried out in 60 patients.

RESULTS

There was no association between EGFr IHC groups and the mean total EGFr levels measured using ELISA.

CONCLUSION

The study shows that the results of different EGFr detection methods do not correlate with each other. Hence, the real role of EGFr in colorectal cancer remains unsettled. Clinically, the receptor itself does not seem to be important and it would be better to focus on EGFr signalling in downstream pathways.

Impact of adjuvant chemotherapy on time to relapse in cholangiocarcinoma

299

Background: Biliary tract cancer is a rare malignancy with poor prognosis. Surgery is the only potential curative approach, but even if surgical intervention is performed correctly the relapse risk remains very high. In adjuvant setting only few randomized trials using no standard treatments and producing controversial data are reported in literature.

Methods: This is a retrospective analysis on 144 consecutive biliary tract cancer patients (pts), undergone potentially curative resection in our institution (109 pts with R0 surgery and 31 pts with R1 surgery). The series included 57 intrahepatic cholangiocarcinomas (ICC), 68 extrahepatic cholangiocarcinomas (ECC), 19 gallbladder cancers (GBC) (Table). Median age was 63, 80 pts were males and 64 pts were females. 80 (60 R0 and 20 R1) out of 144 pts received adjuvant chemotherapy and the remaining 64 pts (49 R0 and 15 R1) started a follow-up program. Adjuvant chemotherapy schedule was gemcitabine 1000 mg/m2 at day 1, 8, 15 every 28, for six months.

Results: Median time to relapse (TTR) in the treatment group and in the follow-up group were 18 months and 11 months respectively (p=0.038). No grade 3-4 chemotherapy-related adverse events were observed and only grade 1-2 thrombocytopenia occurred. This hematologic toxicity did not affect treatment dose intensity.

Conclusions: Our preliminary retrospective analysis suggests a significant advantage of adjuvant treatment on TTR in radically resected biliary tract cancer patients, although further placebo-controlled double blind trials are required.

[Table: see text]

No significant financial relationships to disclose.

Integrative analysis of gene expression profiling and high-resolution genomic copy number in gastrointestinal stromal tumor (GIST)

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Background: Besides mutually exclusive cKIT or PDGFRA mutations, sequential accumulation of other genetic events may be involved in GISTs development and progression, but very few data is still available. Methods: Fresh tissues specimens of GISTs from 10 patients (9 gastric and 1 intestinal) were collected and used for RNA and DNA extraction, labeled and hybridized to HG-U133Plus 2.0 and SNP array 6.0, respectively (Affymetrix). Six patients had exon 9 or exon 11 c-KIT mutation, two PDGFRA mutation, and other two wild-type disease. Gene expression data were quantified by the RMA algorithm, filtered and analysed with supervised techniques (SAM algorithm). Genomic copy number data were analysed with Partek Genomic Suite software against a reference set of 90 Ceu HapMap individuals using a segmentation algorithm with stringent p-value cutoff. Results: Almost all patients exhibited both macroscopic cytogenetic alterations and cryptic microdeletions or amplifications by SNP-array copy number data analysis. The most frequent chromosomal alterations were: 14q complete or partial deletion (7/10), chromosome 19 monosomy (3/10), 22q and 1p deletion (2/10), chromosome 5 trisomy (2/10). The minimal overlapping region ranged from 14q22.3 to 14q32.33, covering a region including 320 genes. The integration of copy number and gene expression data showed that at least 40% of the genes inside the 14q deleted region were significantly downregulated (FDR<10%) in comparison to 14q-diploid patients. In this region several tumor suppressor genes involved in cell cycle checkpoint control (SNW1, CHES1, PPP2R5E), apoptosis induction (PPM1A, MOAP1, PPP1R13B), DNA damage response (MLH3, TDP1), WNT/Notch pathway inhibition (NUMB, DACT1, SEL1L) are located. Conclusions: A wide spectrum of genetic aberrations in GISTs may occur besides c-KIT and PDGFRA mutations. The most frequent is 14q deletion that leads to a significant downregulation of many putative tumor suppressor genes. Combining gene expression and high resolution genomic copy number analysis could identify new haploinsufficient tumor suppressor genes involved in GISTs pathogenesis and tumor progression.

No significant financial relationships to disclose.

Microscopic margins of resection in gastrointestinal stromal tumor (GIST): An analysis of 122 patients

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Background: The main treatment for localized GIST is complete surgical resection. The prognosis is strongly correlated with both tumor size and mitotic index. The aim of our study was to analyze retrospectively the outcome of patients affected by GIST related to microscopic margins of resection. Methods: The outcome of 122 patients surgically managed during the past 11 years, were evaluated. We analyzed the impact of R0 and R1 resection on DFS. Results: All patients but one, had a c-Kit positive GIST, 91% had primary disease without metastasis, 9% had metastasis. There were 46% high, 31% intermediate and 28% low risk GIST. The median age was 65 years (range 29–87). The most common sites of tumor origin were the stomach (54.9%) and the small bowel (36.9%). Sites of tumor metastasis were liver (18.2%), peritoneum (36.4%) or both (19.3%). R0 resection was achieved in 102 (83.6%) patients, while 16 pts (13.1%) had positive microscopic margins (R1). With a median follow up of 24 months (range 3–119), recurrence occurred in 34 (33.3%) R0 and in 9 (56.3%) R1 patients. The median DFS was 53.7 months and 35.6 months for the R0 and R1 group, respectively. The difference tested with univariate analysis using Long rank test, was not statistically significant (p= 0.228). Conclusions: In our series, the status of microscopic margins does not appear to be important for prediction of recurrence in patients affected by GIST.

No significant financial relationships to disclose.

Evaluation of Ki-67 in gastrointestinal stromal tumor (GIST)

e21510

Background: GISTs show a wide spectrum of biological behaviors which translates in an even wider spectrum of possible clinical courses. The two canonical parameters used for the prediction of GISTs’ prognosis are tumor size and mitotic index. However, few but controversial data on Ki-67 are also available. The aim of our study was to clarify the role of Ki-67 expression as a new biological marker in GISTs. Methods: Forty-one cases of GIST were examined. Twenty-six cases arose from stomach and 15 from small bowel. Immunohistochemical analysis for Ki-67 was stained on tissue samples and a cut-off value of >10% immunoreactive cells was used to distinguish between low (<= 10%) and high (>10%) Ki-67 nuclear expression. The expression of this cell-cycle related protein was correlated with tumor site (stomach; any other site), dimensions (<5 cm; >=5cm), mitotic index (<=5/50 HPFs; >5/50 HPFs), standard risk groups (low; intermediate-high) and disease free survival (DFS). Results: Ki-67 over-expression was positively correlated with tumor size >=5cm (p= 0.035). Not significant but a positive trend was seen with intermediate and high risk groups (p = 0.114), mitotic index >5/50 HPFs (p = 0.615). Lower levels of Ki-67 expression have been observed in gastric GISTs compared to any other site (29 cases with Ki-67 <=10% of which 21 gastric and 8 in other sites), even if these values were not statistically significant (p = 0.527). Moreover, Ki-67 over-expression was found to be significantly associated with a shorter DFS interval (p = 0.0196, analysis performed on 32 cases). Conclusions: Our data demonstrate that Ki-67 over-expression is significantly correlated with larger GIST and with a shorter DFS, suggesting that Ki-67 evaluation can be a useful tool to predict biological behavior of GIST, even if further studies are needed. In a clinical perspective, such information could be used in association with standard risk factors to select patients who could benefit from adjuvant therapy.

No significant financial relationships to disclose.

The potential role of IGF1r in young adult patients with gastroinetstinal stromal tumor (GIST)

10562

Background: The insulin-like growth factor 1 receptor (IGF1r) is a tyrosine kinase receptor that plays a key role in the growth of normal tissues. The aberration of IGF system has been found in many cancers. Some interesting results about IGF1r were published on GISTs. However, until now the real role on the pathogenesis of this disease and its clinical implications still needs to be defined. Methods: We studied IGF1r in 8 patients affected by gastric GIST. Seven patients underwent surgery at diagnosis, whereas one patient was operated after imatinib and sunitinib treatment. Two patients were young (< 30 years old), and other patients ranged between 54 and 85 years. IGF1r was studied as gene expression profiling performed with Affymetrix GeneChip HG-U133 Plus 2.0 arrays, as genomic copy number with SNP array analysis Affymetrix Genome Wide Human SNP 6.0 arrays, and with western blotting (WB) usinganti-IGF-IRβ (Santa Cruz Biotechnology). Results: The unsupervised analysis of gene expression profiling of our patients merged with a data set from a gastric GIST identified two groups with different regulation of IGF1r (FDR threshold to 0.2%). In particular, IGF1r was up-regulated in the two youngest patients (28 and 30 years-old). The SNPs array analysis gene copy number showed that none of the patients bore IGF1r amplification. The quantitative analysis of protein level by WB again showed that only the two youngest patients had an over-expression of IGF1r. In all the other patients the WB analysis was negative. Conclusions: These results suggest that IGF1r seems to be a novel signalling pathway other than KIT and PDGFRA in a subset of GISTs. The young adult patients had a strongly different molecular background in comparison to the other older ones. The correlation between IGF1r and mutational status of KIT and PDGFRA, clinical outcome, treatments responsiveness as well as its role as potential target deserves to be further investigated.

No significant financial relationships to disclose.

Effect of the serine proteases inhibitor gabexate mesylate (GM) on the activity of gemcitabine (G) in cell lines of pancreatic cancer (PC)

e15645

Background: Negligible advances for PC treatment have been done over the last decade and G remains the standard. Proteolitic degradation of extracellular matrix (ECM) is essential for early local invasion, metastasis and desmoplastic reaction characterizing PC. Differently from MMPs, the serine proteases (uPA and TAT) action is earlier and larger, degradating not only ECM, but also basement membrane, and activating trypsin, plasmin, angiogenesis via TGF-β1 and proliferation via PAR-2. GM is an inhibitor of u-PA,TAT, trypsin and plasmin, used in Italy and Japan for prophylaxis of acute pancreatitis after ERCP. In a previous study, GM demonstrated antinvasion and antimetastatic activity. Study aim: to evaluate if GM increases G efficacy on pancreatic cancer cell line. Methods: In vitro study of phenotypic effects of GM and G in poor differentiated PANC-1 PC cell line using:1) Cell vitality test (Trypan blu);2) Invasion test (Matrigel invasion assay);3) Cell cycle analysis (cytofluorimeter);4) Antiangiogenic test (tube formation assay in extracellular matrix using E.A.hy926 endothelial cells with matrigel). Different doses of G and GM (100,200,250,500 μM;1mM) alone or combined (concomitant or sequential) have been tested vs controls (PANC-1 without any treatment). All tests have been done in triplicate. Results: G alone (250 μM) decreases invasion by 40% (±5,6%) and cell vitality by 15% (±1,3%.). GM alone (100 μM) decreases invasion by 30% (±4,6%.) but 1mM is needed for similar vitality decrease. GM+G together are detrimental vs G alone while sequential treatment (GM before G with or without 24 hours of interval) enhances G activity. GM (200 μM) and G (250 μM) in immediate sequence show better results decreasing ability of invasion by 75% (±8,3%). Cell vitality is better inhibited from GM (100)/G (250) 24 h-delayed sequence by 28% (±3,8%). Combined treatment mainly blocks cells in G1 phase of cell cycle (5%±0,5%) vs controls. Concerning antiangiogenic assay, the administration of G alone is ineffective to inhibit angiogenesis, while pre-treatment with GM results in a strong anti-angiogenic effect. Conclusions: Association of GM to G could represent a new effective approach to inhibit invasion, angiogenesis and growth in pancreatic cancer.

No significant financial relationships to disclose.

Advances in preclinical therapeutics development using small animal imaging and molecular analyses: the gastrointestinal stromal tumors model

The large use of target therapies in the treatment of gastrointestinal stromal tumors (GISTs) highlighted the urgency to integrate new molecular imaging technologies, to develop new criteria for tumor response evaluation and to reach a more comprehensive definition of the molecular target. These aspects, which come from clinical experiences, are not considered enough in preclinical research studies which aim to evaluate the efficacy of new drugs or new combination of drugs with molecular target. We developed a xenograft animal model GIST882 using nude mice. We evaluated both the molecular and functional characterization of the tumor mass. The mutational analysis of KIT receptor of the GIST882 cell lines and tumor mass showed a mutation on exon 13 that was still present after in vivo cell growth. The glucose metabolism and cell proliferation was evaluated with a small animal PET using both FDG and FLT. The experimental development of new therapies for GIST treatment requires sophisticated animal models in order to represent the tumor molecular heterogeneity already demonstrated in the clinical setting and in order to evaluate the efficacy of the treatment also considering the inhibition of tumor metabolism, and not only considering the change in size of tumors. This approach of cancer research on GISTs is crucial and essential for innovative perspectives that could cross over to other types of cancer.

Experimental results and related clinical implications of PET detection of epidermal growth factor receptor (EGFr) in cancer

The epidermal growth factor receptor (EGFr) is one of the most studied molecules as a target for cancer therapy. Over these last few years, several studies attempting to identify predictive biomarkers of treatment response, such as the receptor status or other molecules related to the downstream signalling pathway, have been conducted. However, from a clinical point of view, the information obtained from ex vivo analyses still has various limitations that may be overcome by the combination with molecular imaging technologies which may provide a noninvasive, global, in vivo evaluation of the molecular tumour background. The aim of this review is to report the preclinical results of all positron emission tomography (PET) tracers synthesized until now for in vivo detection of EGFr in cancer. Two classes of PET compounds have been developed: labelled small molecules such as tyrosine kinase inhibitors and labelled monoclonal antibodies. The in vitro and in vivo results of these PET tracers are very different depending on the chemical properties, positron emission radionuclide, or animal models. As a consequence, various critical questions are still open, and the implications of a translation in the clinical setting for EGFr imaging in cancer patients is discussed.

Molecular imaging and targeted therapies in oncology: new concepts in treatment response assessment. a collection of cases

The widespread use of several new non-cytotoxic drugs and the significant improvements in functional imaging highlights a number of difficulties in monitoring, interpreting and predicting treatment response in clinical practice. Certain guidelines for disease assessment after therapy are already available: the traditional Response Evaluation Criteria in Solid Tumours guidelines based on tumour size variations using conventional imaging technologies, the recent combined method developed by Choi and colleagues in gastrointestinal stromal tumour treated with tyrosine kinase inhibitors based on tumour density variations using computed tomography (CT), and the European Organization for Research and Treatment of Cancer criteria based on tumour glucose metabolism variations using fluorodeoxyglucose (FDG) positron emission tomography (PET). At the moment combined PET/CT response criteria are still not available. A number of new PET compounds other than FDG are also currently being developed to visualize specific cellular and molecular tumour pathways but their role in assessment and prediction of cancer treatment response has not yet been thoroughly investigated in a large series. However, in clinical practice many oncologists treat cancer patients with targeted therapies or chemotherapy and evaluate the response using conventional or functional imaging without appropriate and standardized guidelines. The aim of this study was to present a selection of clinical cases that illustrate the usefulness of new PET tracers and efficacy evaluation of new drugs. In the era of molecular imaging and molecular therapies, these cases highlight the urgency to develop new criteria for treatment assessment and the exigency of correctly interpreting the biological information obtained from new technologies, and introduce new concepts that require further investigation in clinical trials.

Concurrent EGFr and Cox-2 expression in colorectal cancer: proliferation impact and tumour spreading

BACKGROUND

Many reports were produced on single epidermal growth factor receptor (EGFr) and cyclo-oxygenase-2 (Cox-2) evaluation using immunohistochemical techniques (IHC), but very few works considered concurrent expression of these two proteins in the light of their impact on proliferation and tumour spreading. At least three molecular pathways (EGFr, Cox-2, and APC/beta-catenin molecular cascade) may interact in this malignancy giving rise to cross talking effects on proliferation and cancer spreading.

PATIENTS AND METHODS

To better detail these two latter aggressive features, we studied 205 sporadic colorectal cancer patients, comparing concurrent expression of EGFr, Cox-2, Ki-67, Cyclins D1-A, and E, with tumour spreading (budding) (BUD) and pN status.

RESULTS

Our results point to a different aggressive molecular profile due to Cox-2 expression. Cox-2 High expressing cases showed a clear EGFr proliferation-promoting role. On the contrary, EGFr seems directly involved in cancer cells spreading rather than in promoting cancer proliferation in Cox-2 Low/Negative cases.

CONCLUSIONS

Immunohistochemical profiling of colorectal cancer seems to be a promising approach, not only to define prognostic impact, but also to detail proliferation-related molecular interplays between EGFr and Cox-2 pathways, with these two latter proteins, at present, being the hottest pharmacological targets for colorectal cancer (CRC) chemoprevention and therapy.

Conventional and novel PET tracers for imaging in oncology in the era of molecular therapy

In the last ten years, the development of several novel targeted drugs and the refinement of state of the art technologies such as the genomics and proteomics and their introduction to clinical practice have revolutionized the management of patients affected by cancer. However, everyday practice points out several clinical questions: the difficulty of response assessment to new drugs especially using standard RECIST criteria that do not provide information on biological, vascular or metabolic variations; the inadequate selection of patients who are likely to benefit from a targeted therapy excluding those with breast cancer and gastrointestinal stromal tumours; the need to know the global biological background of diseases especially in metastatic setting using repeatable non-invasive procedures. Molecular imaging could provide information on in vivo distribution of biological markers in response to targeted therapy and could improve the selection of patients before therapies. The aim of this review is to analyze the current role of conventional and innovative positron emission tomography (PET) radiotracers in clinical practice and to explore the promising perspectives of molecular imaging in cancer research.

Targeted therapies in solid tumours: results and promises

In these last few years novel approaches to the treatment of solid tumours have been proposed. Therapeutic agents addressed to specific functions of the neoplastic cells seems to be very promising tools, with a low grade of toxicities. These agents are the basis of the so called targeted therapies. Small molecules inhibiting the proliferative cascade of the cancer cells and monoclonal specific antibodies against growth factor or vascular endothelial growth factor have been claimed as the promise in cancer therapy. Unfortunately, the very good results obtained in preclinical experiments have not been completely confirmed in the clinical practice. A selection of patients who could have beneficial effects from the novel agents is mandatory to avoid inappropriate therapies and also unjustified expenses.

Metronomic capecitabine in advanced patients with hepatocellular carcinoma (HCC): Preliminary results

15163

Background: No standard therapies are available for HCC patients (pts) ineligible for curative treatments. HCC has a rich neovasculature and neoangiogenesis is a negative prognostic factor: a high density of microvessels and hyperexpression of VEGF correlates with an increased propensity for invasion and metastatization and with a decreased DFS after resection. High level of circulating endothelial progenitors cells (CEPc) are related with insurgence and progression of HCC. Phase II trials with antiangiogenic agents in monotherapy had a response rate lower than 10% but stable disease (SD) is encouraging ranging between 30 and 60%. Retrospective analysis of standard capecitibine showed a response of 11% and similar SD rate. Experimental data on solid tumors suggest that metronomic CT prolongs inibihition of tumor growth, avoiding CEPc mobilization. Methods: Starting in september 2006, twenty-two patients were started on treatment (19 male; median age 63.7, range 47–82 ). BCLC (Barcelona Consensus Liver Cancer): 5 pts = B; 17 pts = C; Child: 12 pts =A, 8=B, 2=C. 14 pts had portal thrombosis. 15 pts were treated in front line, 7 in second line (4 pts previously treated with Sorafenib and 3 with experimental protocol of CPT-11 HAI; ASCO 2006 Abs 14061 ). The first cycle was carried out with standard capecitabine (2000 mg/sq.mt; 14 over 21 days), followed by metronomic capecitabine (1300 mg) without interruption. To compare the angiogenic role of metronomic capecitabine versus standard administration, VEGF and trombospondine have been dosed at baseline and after the first cycle of standard capecitabine and after one month of metronomic capecitabine. The response has been assessed by CT scan every three months. Results: Five out of 22 patients have been dismissed for toxicity (liver failure) during the standard capecitabine treatment. Among the 17 remaining patients, two have discontinued the treatment due to toxicity (liver failure) during the metronomic treatment and 10 have accomplished at least the first month of metronomic schedule. 6 patients have been evaluated for response: 2 PR (one second line), 3 SD (all in second line), 1 PD (second line). Conclusions: Metronomic capecitabine seems to have a better tolerability than standard schedule and promises good efficacy.

No significant financial relationships to disclose.

GEMOX as first-line chemotherapy in advanced pancreatic cancer (APC): A monoinstitutional experience

15179

Background: To date, gemcitabine (GEM) remains the cornerstone of chemotherapy (CHT) for APC. According to GERCOR and GISCAD phase III trials the combination of GEM and oxaliplatin (GEMOX) has proven superior to GEM alone in terms of response rate (RR), time to progression (TTP) and clinical benefit rate (CBR). Methods: We conducted a retrospective analysis on 19 patients (pts) affected with histologically-confirmed APC, in order to determine the impact of GEMOX as first-line chemotherapy in terms of objective responses (OR) and TTP, using the Kaplan-Meier method. Among the 19 pts considered there were 15 males and 4 females (median age at diagnosis of 60.84 yrs; ECOG 0–2). The staging, according to AJCC criteria, was: IIB in 1 case, III in 5 cases and IV in the 13 remaning cases. The only metastatic site was the liver (in 13/19 pts). Ten of the 19 pts underwent surgical treatment prior to CHT: 2 radically resected (R0) subsequently treated with GEMOX after recurrence, 4 with positive margins (R1) and 4 surgically palliated. All pts received GEM 1000 mg/m2/d1 + oxaliplatin 100 mg/m2/d2 every 2 weeks. The median number of cycles was 5.89. Results: Among the 19 pts, 3 had a partial response (PR, 15.69%), 6 had stable disease (SD, 31.57%); no complete response was observed and 10 pts had progressive disease (PD, 52.63%). The overall disease control rate (DCR: PR + SD) was 47.37% while the OR were 15.69%. The median survival observed was 9.03 months (95% C.I. 5.15–12.91) and the median TTP was 6.13 months (95% C.I. 2.81–9.46). The main toxicities were: leucopenia, piastrinopenia, diarrhoea, nausea, fever and peripheral neuropathy; 3 pts discontinued the treatment due to grade 3–4 neurotoxicity. Conclusions: In our experience GEMOX gives an improved control of APC in terms of OR and TTP, with acceptable toxicity. The OS is in accordance to literature as well as the other data.

No significant financial relationships to disclose.

Gastrointestinal stromal tumors: A monoinstitutional experience

15161

Background: Optimal management of GIST pts required a multidisciplinary approach. Novel tyrosine kinase inhibitors provide an improvement of disease treatment. Methods: We report the clinical results of 67 pts treated in our institution from January 2003 to October 2006, including 41 men and 26 women. Their ages ranged from 28 to 86 yrs (mean 65). 24% of pts were classified into low risk categories, 22% intermediate risk, 54% high risk. At diagnosis, 53/67 patients (79%) presented a localized disease and underwent to surgery, and 14/67 patients (21%) patients presented a metastatic disease. Among these 14 metastatic patients, 8 underwent to surgical removal of primary tumor and metastatic site before treatment with imatinib (2 patient R0) and 6 patients were inoperable at diagnosis and received treatment with imatinib. In total, 61/67 (91%) of patients underwent surgery, R0 resection was achieved in 51 patients. Among 61 operated patients, 24 patients developed a recurrence and received medical treatment with Imatinib. In total, 30/67 (44,7%) patients were treated with Imatinib, and 27 were enrolled in a clinical studies of second line treatment with Sunitinib because of progression or intolerance to treatment with Imatinib. Results: After a follow-up of 42 months we report a median DFS of 14.5 months for radically operated patients. The 3 year-DFS rate was 28.6%. The differential analysis according to risk showed a median DFS of 16.5 months with 16.7% of pts disease free at 3 yrs for the high risk category (36 pts); in the low-intermediate risk categories (31 pts), a median DFS of 21 months with 38% of patients disease-free at 3 yrs was observed. Considering all 38 metastatic pts, 14 at diagnosis and 24 with recurrence, a progressive disease was seen in 94% (median 12 months). In first line of treatment with Imatinib we recorded a median TTP of 17 months with 30% of responders after 2 yrs of treatment. Conclusions: Surgery remains the only curative treatment for localized disease. imatinib is the standard of care for patients with metastatic Gist. For imatinib-resistant GISTs a novel agent such as Sunitinib appears promising.

No significant financial relationships to disclose.

Impact of surgery on the development of duodenal cancer in patients with familial adenomatous polyposis

PURPOSE

Precancerous duodenal lesions in patients with familial adenomatous polyposis can be detected with duodenoscopy and treatment may prevent the development of cancer. We proposed to determine the frequency, natural history, cumulative risk, and risk factors of the precancerous duodenal lesions in a series of patients diagnosed in northern Italy.

METHODS

A prospective, endoscopic, follow-up protocol was performed in 50 patients examined by gastroduodenoscopy at two years of interval or less. The presence and severity of precancerous lesions of the duodenal mucosa were evaluated by Spigelman score. Twenty-five patients (50 percent) had proctocolectomy and ileoanal anastomosis, 15 (30 percent) had colectomy and ileorectal anastomosis, and 5 (10 percent) had proctocolectomy and definitive ileostomy from 0 to 3 years before the admission to the surveillance program. All patients showed more than a thousand adenomas in the colorectal mucosa. No patients with attenuated polyposis were found.

RESULTS

At the first endoscopy, duodenal adenomas could be detected in 19 of 50 patients (38 percent), whereas at the end of the follow-up, 43 (86 percent) had duodenal lesions. The final mean Spigelman score increased during the follow-up period (P<0.001 respect to baseline values). No duodenal cancer could be detected. Eleven patients had or developed severe precancerous duodenal lesions (Stage IV) treated with endoscopic or surgical resection. The distribution of patients with Stage IV according to the surgery of the colon was: 2 of 25 treated with ileoanal anastomosis and 8 of 15 with ileorectal anastomosis (P=0.0024, Fisher's exact test).

CONCLUSIONS

Patients with familial adenomatous polyposis are at risk of significant neoplasia. The natural history of precancerous lesions might be related to surgical treatment of colorectal neoplasms.