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Glockzin G, Helmberger T. Radiologic staging of peritoneal and retroperitoneal disease. ROFO-FORTSCHR RONTG 2023; 195:377-384. [PMID: 36863365 DOI: 10.1055/a-1999-7057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Peritoneal and retroperitoneal tumors consist of a heterogenous group of benign and malignant lesions of different origin. Due to often complex multidisciplinary treatment concepts in patients with peritoneal surface malignancies radiological imaging plays a pivotal role regarding the therapeutic options. Moreover, tumor entity, abdominal tumor distribution and common as well as rare differential diagnoses have to be taken into account. Using different radiological modalities non-invasive pretherapeutic diagnostics might be significantly improved. KEY POINTS:: · Diagnostic CT is a valuable part of the initial diagnostic approach to peritoneal surface malignancies.. · Sensitivity might be increased by the additional use of dwMRI and PET/CT considering tumor entity and individual diagnostic issues.. · The Peritoneal Cancer Index (PCI) should be determined independent of radiologic modality.. CITATION FORMAT: · Glockzin G, Helmberger T. Radiologic staging of peritoneal and retroperitoneal disease. Fortschr Röntgenstr 2023; DOI: 10.1055/a-1999-7057.
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Affiliation(s)
- Gabriel Glockzin
- Department of Surgery, Munchen Klinik Bogenhausen, Munchen, Germany
| | - Thomas Helmberger
- Radiology, Neuroradiology and minimal-invasive Therapy, Munchen Klinik Bogenhausen, Munchen, Germany
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Piso P, Nedelcut SD, Rau B, Königsrainer A, Glockzin G, Ströhlein MA, Hörbelt R, Pelz J. Morbidity and Mortality Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: Data from the DGAV StuDoQ Registry with 2149 Consecutive Patients. Ann Surg Oncol 2018; 26:148-154. [PMID: 30456672 DOI: 10.1245/s10434-018-6992-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are performed for well-selected patients with peritoneal surface malignancies. This combined treatment is potentially associated with an increased rate of complications. OBJECTIVE The aim of this paper was to analyze the morbidity and mortality of CRS and HIPEC in the German national registry. METHODS We present a retrospective analysis of 2149 consecutive patients from 52 hospitals. The data were prospectively documented in the DGAV StuDoQ Registry between February 2011 and December 2016. RESULTS Almost two-thirds of all patients had a colorectal malignancy; therefore, the most frequently performed resections were colectomies (54%) and rectal resections (30%). Only 36.2% of all patients had no anastomosis, and fewer than 20% of all patients were older than 70 years of age (16.4%). Enteric fistula and anastomotic leaks occurred in 10.5% of all cases. The reoperation rate was 14.6% (95% confidence interval [CI] 11.51-18.1). Major grade 3 and 4 complications (Clavien-Dindo classification) occurred in 19.3% of all patients, half of which were due to surgical complications. The overall 30-day postoperative hospital mortality was 2.3% (95% CI 1.02-3.85). Multivariate analysis showed an increased risk for morbidity associated with pancreatic resections (odds ratio [OR] 2.4), rectal resection (OR 1.5), or at least one anastomosis (OR 1.35), and mortality with reoperation (OR 8.7) or age > 70 years (OR 3.35). CONCLUSIONS CRS and HIPEC are associated with acceptable morbidity and low mortality. These results show that CRS and HIPEC can be safely performed nationwide when close mentoring by experienced centers is provided.
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Affiliation(s)
- Pompiliu Piso
- Department of General and Visceral Surgery, Hospital Barmherzige Brüder, Regensburg, Germany.
| | - Sebastian D Nedelcut
- Department of General and Visceral Surgery, Hospital Barmherzige Brüder, Regensburg, Germany
| | - Beate Rau
- Department of Surgery, Campus Virchow-Klinikum and Charité Campus Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Alfred Königsrainer
- Department of General, Visceral and Transplant Surgery, Eberhard-Karls University Hospital, Tübingen, Germany
| | - Gabriel Glockzin
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany.,Department of Surgery, Städtisches Klinikum München GmbH, Klinikum Bogenhausen, München, Germany
| | - Michael A Ströhlein
- Department of Abdominal, Vascular and Transplant Surgery, Köln-Merheim Medical Center, Witten/Herdecke University, Köln, Germany
| | - Rüdiger Hörbelt
- Department of Surgery, University Hospital of Giessen-Marburg, Giessen, Germany
| | - Jörg Pelz
- Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital Würzburg, Würzburg, Germany
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Glockzin G, Zeman F, Croner RS, Königsrainer A, Pelz J, Ströhlein MA, Rau B, Arnold D, Koller M, Schlitt HJ, Piso P. Perioperative Systemic Chemotherapy, Cytoreductive Surgery, and Hyperthermic Intraperitoneal Chemotherapy in Patients With Colorectal Peritoneal Metastasis: Results of the Prospective Multicenter Phase 2 COMBATAC Trial. Clin Colorectal Cancer 2018; 17:285-296. [PMID: 30131226 DOI: 10.1016/j.clcc.2018.07.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 07/21/2018] [Accepted: 07/24/2018] [Indexed: 01/29/2023]
Abstract
BACKGROUND Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) as parts of an interdisciplinary treatment concept including systemic chemotherapy can improve survival of selected patients with peritoneal metastatic colorectal cancer (pmCRC). Nevertheless, the sequence of the therapeutic options is still a matter of debate. Thus, the COMBATAC (COMBined Anticancer Treatment of Advanced Colorectal cancer) trial was conducted to evaluate a combined treatment regimen consisting of preoperative systemic polychemotherapy + cetuximab followed by CRS + HIPEC and postoperative systemic polychemotherapy + cetuximab. PATIENTS AND METHODS The COMBATAC trial is a prospective, multicenter, open-label, single-arm, single-stage phase 2 trial. Twenty-six patients with synchronous or metachronous colorectal or appendiceal peritoneal carcinomatosis were included. Enrollment was terminated prematurely by the sponsor because of slow recruitment. Progression-free survival as primary end point and overall survival were estimated by the Kaplan-Meier method. Also evaluated were morbidity according to Common Terminology Criteria for Adverse Events v4.0 and feasibility of the combined treatment concept. RESULTS Median progression-free survival for the intention-to-treat population (n = 25) was 14.9 months. Median overall survival was not reached during the study duration. Ninety-two adverse events were documented in 16 patients, including 14 serious adverse events in 9 patients. The overall morbidity rate was 64%, and the grade 3/4 morbidity rate was 44%. Of all grade 3/4 morbidity events, 36.4% were related to systemic chemotherapy and 22.7% to surgery, whereas 40.9% were not directly related. There was no treatment-related mortality. CONCLUSION The results of the COMBATAC trial show that the multimodal treatment concept consisting of perioperative systemic chemotherapy and CRS + HIPEC is safe and feasible. Progression-free survival in selected patients with colorectal or appendiceal peritoneal metastasis might be improved.
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Affiliation(s)
- Gabriel Glockzin
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany; Department of Surgery, Klinikum Bogenhausen, Munich, Germany.
| | - Florian Zeman
- Center for Clinical Studies, University Medical Center Regensburg, Regensburg, Germany
| | - Roland S Croner
- Department of Surgery, University of Erlangen-Nuremberg, Erlangen, Germany; Department of Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Alfred Königsrainer
- Department of Surgery, University of Tübingen, Comprehensive Cancer Center, Tübingen, Germany
| | - Jörg Pelz
- Department of Surgery, University Hospital Würzburg, Würzburg, Germany; Department of Surgery, St Bernward Hospital, Hildesheim, Germany
| | - Michael A Ströhlein
- Department of Abdominal, Vascular and Transplant Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Cologne, Germany
| | - Beate Rau
- Department of Surgery, Campus Virchow and Mitte, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Dirk Arnold
- Asklepios Tumor Center Hamburg, AK Altona, Department of Oncology, Hamburg, Germany
| | - Michael Koller
- Center for Clinical Studies, University Medical Center Regensburg, Regensburg, Germany
| | - Hans J Schlitt
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Pompiliu Piso
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany; Department of Surgery, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany
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Seebauer CT, Brunner S, Glockzin G, Piso P, Ruemmele P, Schlitt HJ, Geissler EK, Fichtner-Feigl S, Kesselring R. Peritoneal carcinomatosis of colorectal cancer is characterized by structural and functional reorganization of the tumor microenvironment inducing senescence and proliferation arrest in cancer cells. Oncoimmunology 2016; 5:e1242543. [PMID: 28439450 DOI: 10.1080/2162402x.2016.1242543] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 09/21/2016] [Accepted: 09/23/2016] [Indexed: 12/19/2022] Open
Abstract
Background : Peritoneal carcinomatosis (PC) is a terminal evolution from primary colorectal cancer (pCRC) associated with poor patient survival. Impact of the immune cell infiltrate on PC pathogenesis is unknown. Therefore, we characterized the immunological tumor microenvironment regarding proliferation, senescence and neovascularization. Methods : Formalin-fixed and paraffin-embedded (FFPE) tissue of PC and pCRC was examined by immunohistochemistry. Cells infiltrating resected tissue were isolated and analyzed by flow cytometry. PCR arrays detected the expression of genes relevant for helper T (TH) cell responses, like TH1, TH2 and TH17 response. Results : PC tumor cells demonstrate significantly lower proliferation rates than pCRC, but show significantly more senescence. PC is surrounded by significantly increased numbers of cytotoxic active Natural Killer (NK) cells, follicular helper T cells (TFH) and B cells, whereas pCRC shows more CD4+ TH cells, CD8+ cytotoxic T (TC) cells, eosinophilic granulocytes, TH17 and regulatory T (Treg) cells. PC is characterized by significantly increased interferon-γ (IFNγ), an upregulation of tumor necrosis factor (TNF) and the NK cell-regulating cytokine interleukin-15 (IL-15). An upregulation of angiogenesis-related genes, like vascular endothelial growth factor-A (VEGF-A), leads to severe neovascularization in PC. Correlations of PC results reveal that elevated numbers of interleukin-17 (IL-17) positive cells are associated with high cancer cell proliferation, whereas high numbers of IFNγ positive cells correlate with more tumor cells in senescence. Conclusion : The cellular immune reaction is modified during metastasis, inducing senescence in PC tumor cells. Immune surveillance in PC is facilitated by NK cells and high levels of IFNγ and TNF. Counteracting this effect, TFH and B cells combined with VEGF-A enhancement promote neovascularization in PC (Illustration 1). During metastasis from primary CRC to PC the immune cell infiltrate changes, accompanied by the induction of senescence in PC cancer cells (marked red): In pCRC, the antitumor immune response is facilitated by CD4+TH cells, CD8+TC cells and PRG2+ eosinophilic granulocytes. The premetastatic niche development is promoted by Treg cells and TH17 cells producing systemic factors like VEGF-A, TGF-β and TNF. Along with TFH and B cells, as with a pro-tumor immune response, they support metastatic formation and lead to severe neovascularization in PC. This is counterbalanced by the IL-15-induced activation and proliferation of NK cells. The secreted cytokines IFNγ and TNF mediate immunosurveillance.
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Affiliation(s)
| | - Stefan Brunner
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Gabriel Glockzin
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Pompiliu Piso
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Petra Ruemmele
- Department of Pathology, University Medical Center Regensburg, Regensburg, Germany
| | - Hans-Juergen Schlitt
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | | | - Stefan Fichtner-Feigl
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany.,Regensburg Center of Interventional Immunology, Regensburg, Germany
| | - Rebecca Kesselring
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany.,Regensburg Center of Interventional Immunology, Regensburg, Germany
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Glockzin G, Schlitt HJ, Piso P. Therapeutic options for peritoneal metastasis arising from colorectal cancer. World J Gastrointest Pharmacol Ther 2016; 7:343-352. [PMID: 27602235 PMCID: PMC4986391 DOI: 10.4292/wjgpt.v7.i3.343] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/22/2016] [Accepted: 07/13/2016] [Indexed: 02/06/2023] Open
Abstract
Peritoneal metastasis is a common sign of advanced tumor stage, tumor progression or tumor recurrence in patients with colorectal cancer. Due to the improvement of systemic chemotherapy, the development of targeted therapy and the introduction of additive treatment options such as cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), the therapeutic approach to peritoneal metastatic colorectal cancer (pmCRC) has changed over recent decades, and patient survival has improved. Moreover, in contrast to palliative systemic chemotherapy or best supportive care, the inclusion of CRS and HIPEC as inherent components of a multidisciplinary treatment regimen provides a therapeutic approach with curative intent. Although CRS and HIPEC are increasingly accepted as the standard of care for selected patients and have become part of numerous national and international guidelines, the individual role, optimal timing and ideal sequence of the different systemic, local and surgical treatment options remains a matter of debate. Ongoing and future randomized controlled clinical trials may help clarify the impact of the different components, allow for further improvement of patient selection and support the standardization of oncologic treatment regimens for pmCRC. The addition of further therapeutic options such as neoadjuvant intraperitoneal chemotherapy or pressurized intraperitoneal aerosol chemotherapy, should be investigated to optimize therapeutic regimens and further improve the oncological outcome.
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Schenk KE, Schierl R, Angele M, Burkhart-Reichl A, Glockzin G, Novotny A, Nowak D. Cisplatin and oxaliplatin surface contamination in intensive care units (ICUs) and hospital wards during attendance of HIPEC patients. Int Arch Occup Environ Health 2016; 89:991-6. [PMID: 27142971 DOI: 10.1007/s00420-016-1137-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 04/21/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE The aim of this pilot study was to evaluate surface contamination by platinum drugs in the environment of patients in ICUs and wards treated by hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS The monitoring included 12 HIPEC treatments from four hospitals during the following 3 days after perfusion. A total of 33 urine and 33 drainage fluids from HIPEC patients and 160 wipe samples from several surfaces (urine/drainage bags, floors, gloves) were taken during the study period. RESULTS In urine, the highest platinum concentrations were measured on the first day after perfusion. Median platinum concentrations were 1260 ng/ml for patients after cisplatin perfusion and 11,000 ng/ml for oxaliplatin treatment. Concentrations decreased until day three to 413 ng/ml cisplatin and 529 ng/ml oxaliplatin, respectively. In drainage liquids, platinum concentrations were generally lower. Platinum concentrations from surfaces of bags and floors ranged from 0.01 to 439 pg/cm(2) (median: urine bag 2.77 pg/cm(2), drainage bag 0.22 pg/cm(2), floor left 0.14 pg/cm(2), floor right 0.24 pg/cm(2)), with the highest contamination found on the outer surface of the urine bags. Samples from nurses' protective gloves ranged between 0.03 and 12 pg/cm(2) (median: 0.2 pg/cm(2)). CONCLUSIONS High platinum-drug concentrations in urine and drainage liquids are the main source of contamination. Therefore, safe handling of these liquids is the best way to avoid cross-contamination on surfaces in wards and ICUs. Our results show that it is possible to take care of HIPEC patients without high contaminations during the first 3 days.
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Affiliation(s)
- K-E Schenk
- Occupational, Social and Environmental Medicine, University Hospital Munich, Munich, Germany
| | - R Schierl
- Occupational, Social and Environmental Medicine, University Hospital Munich, Munich, Germany.
| | - M Angele
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital Munich, Munich, Germany
| | - A Burkhart-Reichl
- Occupational Medicine, Barmherzige Brüder Hospital, Regensburg, Germany
| | - G Glockzin
- Department of General, Visceral, Endocrine and Minimal Invasive Surgery, Hospital Bogenhausen, Munich, Germany
| | - A Novotny
- Department of Surgery, Hospital Rechts der Isar, Technical University Munich, Munich, Germany
| | - D Nowak
- Occupational, Social and Environmental Medicine, University Hospital Munich, Munich, Germany
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Abstract
Colorectal metastases still represent a challenge to all oncologists despite progresses achieved by improved resectability, systemic chemotherapy and targeted therapies. In particular in patients with oligo-metastases, the role of surgical resections has been redefined. Resection is the most effective treatment method for liver metastases performed with curative intent; however, primary rate of resectability is low. Several methods to increase resectability have been developed: conversion chemotherapy, portal vein embolization, two-stage resections, vascular reconstruction of the liver veins, combination of resection and intraoperative ablation. Liver resections can be performed at present with low mortality. Patients with isolated peritoneal metastases, no extra-abdominal disease, low volume tumor and complete surgical cytoreduction do benefit from surgery and hyperthermic intraperitoneal chemotherapy. Several national guidelines recommend multimodality treatment for highly selected patients. The management of stage IV colorectal cancer includes several disciplines with focus on resection. A multidisciplinary evaluation of all patients is of crucial importance to define the treatment sequence and individual strategies for each patient.
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Affiliation(s)
- Pompiliu Piso
- Department for General- and Visceral Surgery, Hospital Barmherzige Brueder, Pruefeninger Str. 86, 93049 Regensburg Germany
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Lang SA, Loss M, Benseler V, Glockzin G, Schlitt HJ. Long-term results after in-situ split (ISS) liver resection. Langenbecks Arch Surg 2015; 400:361-9. [PMID: 25854503 DOI: 10.1007/s00423-015-1285-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 02/08/2015] [Indexed: 02/07/2023]
Abstract
PURPOSE In-situ split (ISS) liver resection is a novel method to induce rapid hypertrophy of the contralateral liver lobe in patients at risk for postoperative liver failure due to insufficient liver remnant. So far, no data about oncological long-term survival after ISS liver resection is available. METHODS We retrospectively analyzed our patients treated with ISS liver resection at the Department of Surgery of the University of Regensburg, the first center worldwide to perform ISS. RESULTS Between 2007 and 2014, ISS liver resection was performed in 16 patients. Two patients (12.5 %) were lost in early postoperative phase (90 days) and one was lost to follow-up. Thirteen patients with a follow-up period of more than 3 months were included into oncologically focused analyses. Median follow-up was 26.4 months (range 3.2-54.6). Seven patients had suffered from colorectal liver metastases (CRLM) and six from various other liver malignancies (non-CRLM). The ISS procedure had led to a median increase of 86.3 % of the left lateral liver lobe after a median of 9 days (range 4-28 days). Median disease-free survival (DFS) was 14.6 months and median overall survival (OS) was 41.7 months (26.4 months when including 90-days mortality). Three-year survival was calculated with 56.4 and 48.9 % when including perioperative mortality, respectively (CRLM 64.3 % vs. non-CRLM 50 %). CONCLUSION ISS liver resection can provide long-term survival of selected patients with advanced liver malignancies that otherwise are not eligible for liver resection due to insufficient liver remnant.
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Affiliation(s)
- Sven A Lang
- Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauss Allee 11, 93053, Regensburg, Germany,
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Glockzin G, Gerken M, Lang SA, Klinkhammer-Schalke M, Piso P, Schlitt HJ. Oxaliplatin-based versus irinotecan-based hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with peritoneal metastasis from appendiceal and colorectal cancer: a retrospective analysis. BMC Cancer 2014; 14:807. [PMID: 25369730 PMCID: PMC4228082 DOI: 10.1186/1471-2407-14-807] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 10/23/2014] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) provide an effective treatment option for selected patients with colorectal peritoneal metastasis with encouraging survival results. Many different drug combinations and HIPEC regimens including bidirectional, i.e. synchronous intravenous and intraperitoneal, drug application have been used. However, there is still no standardization of the HIPEC regimen. METHODS Between 05/2007 and 04/2010 190 patients underwent CRS and HIPEC at the University Hospital Regensburg. Thirty-two patients with peritoneal metastasis arising from colorectal or appendiceal cancer underwent complete macroscopic cytoreduction (CC-0/1) and bidirectional HIPEC and completed at least 3-year follow-up. Twenty patients received oxaliplatin-based (OX) and twelve patients received irinotecan-based HIPEC (IRI). Group-specific perioperative morbidity and 3-year survival has been determined. RESULTS The grade 3/4 morbidity rate according to CTCAE v4 was 35.0% in the OX group vs. 33.3% in the IRI group (p = 1.000). There was no perioperative mortality in both groups. Median survival was 26.8 months (95% CI 15.7-33.1 months) in the IRI group and has not yet been reached in the OX group during a median follow-up of 39.4 months. Three-year survival rates were 65.0% in the OX group vs. 41.7% in the IRI group (p = 0.295). CONCLUSIONS The morbidity and toxicity rates of bidirectional irinotecan-based and oxaliplatin-based HIPEC are comparable. Nevertheless, in the absence of contraindications oxaliplatin-based HIPEC might be preferred due to the positive trend regarding 3-year and median survival.
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Affiliation(s)
- Gabriel Glockzin
- Department of Surgery, University Hospital Regensburg, 93042 Regensburg, Germany.
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Esquivel J, Piso P, Verwaal V, Bachleitner-Hofmann T, Glehen O, González-Moreno S, Deraco M, Pelz J, Alexander R, Glockzin G. American Society of Peritoneal Surface Malignancies opinion statement on defining expectations from cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with colorectal cancer. J Surg Oncol 2014; 110:777-8. [PMID: 25043759 DOI: 10.1002/jso.23722] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 06/10/2014] [Indexed: 01/31/2023]
Affiliation(s)
- Jesus Esquivel
- Department of Surgical Oncology, Cancer Treatment Centers of America, Philadelphia, Pennsylvania
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Piso P, Koller M, Arnold D, Schlitt HJ, Glockzin G. Multimodality treatment of colorectal peritoneal metastasis with perioperative systemic chemotherapy, cytoreductive surgery (CRS), and HIPEC: First safety results of the COMBATAC trial. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.3_suppl.lba382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
LBA382 Background: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) provide a promising therapeutic option as part of an interdisciplinary multimodal treatment regimen for selected patients with peritoneal metastasis arising from colorectal cancer. The COMBATAC trial evaluates the feasibility, safety, and efficacy of perioperative cetuximab-containing systemic polychemotherapy, CRS and bidirectional oxaliplatin-based HIPEC. Methods: The COMBATAC trial is a prospective, multicenter, open-label, single-arm, single-stage phase II trial recruiting patients with histologically proven wild-type KRAS colorectal or appendiceal adenocarcinoma and synchronous or metachronous peritoneal metastasis. The planned total number of patients to be recruited is 60. The primary endpoint is progression-free survival (PFS). Results: Preliminary data of the first 16 documented patients show a total number of 51 adverse events. According to CTCAE v4 the distribution of AE was 23 grade 1, 14 grade 2, 13 grade 3, and one grade 4, respectively. Of the 14 grade 3/4 adverse events three were chemotherapy-related, four surgery-related, and seven not directly treatment-related. Most common grade 3/4 complications were infection, thrombosis, and urinary tract obstruction. Conclusions: First data indicate that perioperative systemic polychemotherapy including cetuximab in combination with CRS and bidirectional HIPEC is feasible and might not lead to increased morbidity and toxicity rates. Nevertheless, the COMBATAC trial is still recruiting, and data regarding progression-free survival (PFS) and overall survival (OS) is not yet available. Clinical trial information: NCT01540344.
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Affiliation(s)
- Pompiliu Piso
- Department of Surgery, Hospital of the Order of St. John of God Regensburg, Regensburg, Germany
| | - Michael Koller
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - Dirk Arnold
- Tumor Biology Center, Albert Ludwigs University, Freiburg, Germany
| | - Hans J. Schlitt
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Gabriel Glockzin
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
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Glockzin G, Gerken M, Lang SA, Schlitt HJ, Piso P. Comparison of two bidirectional hyperthermic intraperitoneal chemotherapy (HIPEC) regimens in patients with colorectal peritoneal metastasis. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.3_suppl.628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
628 Background: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) became part of many national and international treatment guidelines as an additive therapeutic option for selected patients with colorectal peritoneal metastasis. Multiple HIPEC regimens are used regarding cytotoxic agents, concentration, perfusion time an other parameters and consistent data for standardization is missing. Methods: 32 consecutive patients after complete macroscopic cytoreduction (CC-0/1) and bidirectional HIPEC for colorectal peritoneal metastasis were retrospectively analyzed. Twenty patients received oxaliplatin-based and twelve patients received irinotecan-based HIPEC. Morbidity and toxicity according to CTCAE v4, mortality and 3-year survival rates hava been determined. Results: The overall 3/4 morbidity rate was 34.4 % and the perioperative mortality rate 0 % in both groups (p = 1.000). Median survival was 26.8 months (95 % CI 15.7-33.1 months) in the IRI group and has not yet been reached in the OX group. 3-year survival rates were 65.0 % in the OX group vs. 41.7 % in the IRI group (p = 0.295). Conclusions: Both HIPEC regimens showed comparable morbidity and toxicity. Nevertheless, oxaliplatin-based HIPEC might be preferred due to the not significant positive survival trend. Prospective randomized trials are needed to compare the different HIPEC regimens and to determine the most effective therapeutic approach.
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Affiliation(s)
- Gabriel Glockzin
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Michael Gerken
- Tumor Center Regensburg e. V., University Regensburg, Regensburg, Germany
| | - Sven A. Lang
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Hans J. Schlitt
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Pompiliu Piso
- Department of Surgery, Hospital of the Order of St. John of God Regensburg, Regensburg, Germany
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von Breitenbuch P, Jeiter T, Schreml S, Glockzin G, Agha A, Piso P, Schlitt HJ. Autofluorescent imaging in patients with peritoneal carcinomatosis. Surg Innov 2013; 21:187-93. [PMID: 23843158 DOI: 10.1177/1553350613495114] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND OBJECTIVES Autofluorescence imaging (AFI) is mainly used to detect (pre)cancerous colorectal and pulmonal lesions. This is the first report establishing the feasibility of AFI in patients with peritoneal carcinomatosis (PC). METHODS This is a prospective analysis of 10 patients undergoing conventional white-light laparoscopy (WL) and AFI for PC of different gastrointestinal tumors and 1 ovarian cancer. Before taking biopsies, suspicious peritoneal lesions were first detected by WL and then investigated by AFI. The intraoperative findings were photographed and then correlated with histological results. RESULTS Conventional WL and AFI evaluation was successful in all patients. A total of 38 biopsies were taken. The neoplasm detection rate under WL was 66% and increased to 86% when using AFI. The positive tumor detection rate was slightly higher in low AF lesions (83 vs 88%) and higher in tumor nodules (94%) than in flat peritoneal lesions (75%). For tumor nodules, the sensitivity was 94%, and the specificity was 100%. For flat lesions, the sensitivity was 75% and specificity 50%. CONCLUSIONS We demonstrate the feasibility and effectiveness of AFI in patients with PC.
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Glockzin G, Rochon J, Arnold D, Lang SA, Klebl F, Zeman F, Koller M, Schlitt HJ, Piso P. A prospective multicenter phase II study evaluating multimodality treatment of patients with peritoneal carcinomatosis arising from appendiceal and colorectal cancer: the COMBATAC trial. BMC Cancer 2013; 13:67. [PMID: 23391248 PMCID: PMC3575316 DOI: 10.1186/1471-2407-13-67] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 02/04/2013] [Indexed: 12/15/2022] Open
Abstract
Background Peritoneal carcinomatosis is regarded as a common sign of advanced tumor stage, tumor progression or local recurrence of appendiceal and colorectal cancer and is generally associated with poor prognosis. Although survival of patients with advanced stage CRC has markedly improved over the last 20 years with systemic treatment, comprising combination chemotherapy +/− monoclonal antibodies, the oncological outcome—especially of the subgroup of patients with peritoneal metastases—is still unsatisfactory. In addition to systemic therapy, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are specific treatment options for a selected group of these patients and may provide an additional therapeutic benefit in the framework of an interdisciplinary treatment concept. Methods/design The COMBATAC trial is a prospective, multicenter, open-label, single-arm, single-stage phase II trial investigating perioperative systemic polychemotherapy including cetuximab in combination with CRS and HIPEC patients with histologically proven wild-type KRAS colorectal or appendiceal adenocarcinoma and synchronous or metachronous peritoneal carcinomatosis. The planned total number of patients to be recruited is 60. The primary endpoint is progression-free survival (PFS). Secondary endpoints include overall survival (OS), perioperative morbidity and treatment-associated toxicity, feasibility of the combined treatment regimen, quality of life (QoL) and histopathological regression after preoperative chemotherapy. Discussion The COMBATAC trial is designed to evaluate the feasibility and efficacy of the combined multidisciplinary treatment regimen consisting of perioperative systemic combination chemotherapy plus cetuximab and CRS plus bidirectional HIPEC with intraperitoneal oxaliplatin. Trial registration ClinicalTrials.gov Identifier: NCT01540344, EudraCT number: 2009-014040-11
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Affiliation(s)
- Gabriel Glockzin
- Department of Surgery, University Medical Center Regensburg, Regensburg 93042, Germany.
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15
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Glockzin G, Piso P, Schlitt HJ. Surgical Approach Including Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in Patients with Peritoneal Metastasis. Visc Med 2013; 29:220-225. [DOI: 10.1159/000354134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
<b><i>Background: </i></b>Peritoneal metastasis arising from colorectal cancer, appendiceal cancer, gastric cancer and gynecologic malignancies, or primary peritoneal surface malignancies such as peritoneal mesothelioma and primary peritoneal adenocarcinoma may be efficiently treated by cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in selected patients. <b><i>Method: </i></b>CRS is based on the technique of parietal and visceral peritonectomy and consists of multiple surgical procedures. HIPEC combines high local doses of cytostatics with the additional cytotoxic effects of hyperthermia. <b><i>Results: </i></b>The goal of CRS is to achieve a complete macroscopic cytoreduction (CC-0/1) as a precondition for consecutive HIPEC that should destroy residual tumor cells within the abdominal cavity. <b><i>Conclusion: </i></b>CRS and HIPEC can be performed with acceptable morbidity and low mortality in specialized centers. However, due to long learning curves, consistent surgical training is strongly recommended.
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Stein A, Glockzin G, Wienke A, Arnold D, Edelmann T, Hildebrandt B, Hollerbach S, Illerhaus G, Königsrainer A, Richter M, Schlitt HJ, Schmoll HJ. Treatment with bevacizumab and FOLFOXIRI in patients with advanced colorectal cancer: presentation of two novel trials (CHARTA and PERIMAX) and review of the literature. BMC Cancer 2012; 12:356. [PMID: 22897915 PMCID: PMC3503684 DOI: 10.1186/1471-2407-12-356] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Accepted: 07/17/2012] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND More than half of patients with colorectal cancer will develop metastatic disease either evident at the time of initial diagnosis or during their course of disease. Besides multidisciplinary management further treatment intensification is warranted to improve the still limited prognosis. METHODS/DESIGN In these two multi-centre, randomized phase II trials, conducted in Germany, 380 patients with R0-resectable colorectal liver metastases (PERIMAX) and with unresectable, metastatic colorectal cancer (CHARTA) will be recruited. Patients previously untreated for metastatic disease with either synchronous or metachronous metastases are randomly assigned in a 1:1 ratio to resection of colorectal liver metastases followed by postoperative FOLFOX for 6 months or perioperative FOLFOXIRI and bevacizumab for 3 months pre- and postoperative and resection (PERIMAX), or to induction chemotherapy with FOLFOX and bevacizumab +/- irinotecan for a maximum of 6 months followed by maintenance treatment with fluoropyrimidine and bevacizumab. The primary objective of these trials is to evaluate the feasibility and efficacy of FOLFOXIRI and bevacizumab in metastatic colorectal cancer. Primary endpoint is failure free survival rate at 18 months in the PERIMAX trial and progression free survival rate at 9 months in CHARTA. Secondary objectives include efficacy, safety and tolerability. DISCUSSION The CHARTA and PERIMAX trials are designed to evaluate the benefits and limitations of a highly active four-drug regimen in distinct treatment situations of metastatic CRC. Eligible patients are classified into resectable liver metastases to be randomized to perioperative treatment with FOLFOXIRI and bevacizumab or postoperative FOLFOX in the PERIMAX, or unresectable metastatic CRC to be randomized between FOLFOX and bevacizumab with or without irinotecan, stratified for clinical groups according to disease and patients' characteristics in the CHARTA trial. TRIAL REGISTRATION Clinical trial identifier CHARTA: NCT01321957, PERIMAX: NCT01540435.
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Affiliation(s)
- Alexander Stein
- University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Glockzin
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Andreas Wienke
- Department for Oncology/Hematology, Martin-Luther-University Halle, Ernst-Grube-Str. 40, 06120, Halle/Saale, Germany
| | - Dirk Arnold
- University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Bert Hildebrandt
- Charité Centrum für Tumormedizin, Campus Virchow-Klinikum, Berlin, Germany
| | - Stephan Hollerbach
- Department for Gastroenterology, Academic Teaching Hospital, Celle, Germany
| | - Gerald Illerhaus
- Department of Hematology/Oncology, Comprehensive Cancer Center University of Freiburg, Freiburg, Germany
| | | | - Michael Richter
- Koordinierungszentrum Klinische Studien Halle, Martin-Luther-University, Halle, Germany
| | - Hans J Schlitt
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Hans-Joachim Schmoll
- Department for Oncology/Hematology, Martin-Luther-University Halle, Ernst-Grube-Str. 40, 06120, Halle/Saale, Germany
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Glockzin G, von Breitenbuch P, Schlitt HJ, Piso P. Treatment-related morbidity and toxicity of CRS and oxaliplatin-based HIPEC compared to a mitomycin and doxorubicin-based HIPEC protocol in patients with peritoneal carcinomatosis: a matched-pair analysis. J Surg Oncol 2012; 107:574-8. [PMID: 22833286 DOI: 10.1002/jso.23228] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Accepted: 07/05/2012] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) provide a promising therapeutic option for selected patients with peritoneal carcinomatosis. The use of intraperitoneal oxaliplatin seems to further improve the efficacy of the combined treatment concept. Nevertheless, additional toxicity might be expected. PATIENTS AND METHODS Between 03/2004 and 08/2010 307 patients underwent CRS and HIPEC at the University Medical Center Regensburg. Forty of these patients received oxaliplatin-based HIPEC. A matched-pair analysis was performed to compare IP oxaliplatin to our former standard HIPEC protocol with mitomycin C (MMC) and doxorubicin. RESULTS The mean operating time in the OX and the MMC group was 315 and 313 min, respectively. Median hospital stay was 15.5 days in the OX group and 17 days in the MMC group. The grade 3/4 morbidity rate according to CTCAEv3.0 was 42.5% versus 37.5% (P = 0.648). Perioperative mortality was 2.5% versus 0%. CONCLUSION Our data suggest that the use of IP oxaliplatin in the context of CRS and HIPEC does not significantly increase perioperative morbidity and/or mortality rates. Nevertheless, randomized controlled trials are required to determine the optimal intraperitoneal chemotherapeutic regimen regarding toxicity, postoperative complications, and oncological outcome.
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Affiliation(s)
- Gabriel Glockzin
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
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18
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Glockzin G, Hornung M, Kienle K, Thelen K, Boin M, Schreyer AG, Lighvani HR, Schlitt HJ, Agha A. Completion thyroidectomy: effect of timing on clinical complications and oncologic outcome in patients with differentiated thyroid cancer. World J Surg 2012; 36:1168-1173. [PMID: 22366982 DOI: 10.1007/s00268-012-1484-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite improved preoperative diagnostics, incidental postoperative detection of differentiated thyroid cancer in the final histology is still common. In most of these cases, completion thyroidectomy is recommended by national and international guidelines, although secondary surgery is associated with an increased operative risk. The optimal timing of completion thyroidectomy is still controversial. METHODS Between January 1993 and December 2009, a total of 128 patients underwent completion thyroidectomy for differentiated thyroid carcinoma: papillary (n = 87) and follicular (n = 41). These patients were divided into five groups according to the time of the completion thyroidectomy after primary surgery (groups A, 1-3 days; B, 4-7 days; C, 1-7 weeks; D, 7-12 weeks; E, >3 months). Clinical complications and oncologic outcomes were analyzed. The mean follow-up was 82.5 ± 17 months. RESULTS The overall rates of transient and persistent postoperative hypocalcemia were 7.0 and 3.1%, respectively. The rates of persistent hypocalcemia were significantly increased in groups B, C, and D in comparison to those in groups A and E (p < 0.003). The hypocalcemia rates were 7.1, 4.5, and 3.8% versus 0%, respectively. Transient or persistent vocal cord paresis was observed in eight (6.2%) and four patients (3.1%), respectively. The incidence of persistent vocal cord paresis (VCP) was significantly higher in groups B, C, and D than in groups A and E (p < 0.003). The VCP rates were 7.1, 4.5, and 3.8% versus 0%, respectively. There was no significant difference regarding survival or recurrence among the five groups. CONCLUSIONS Considering perioperative morbidity and oncologic outcomes, completion thyroidectomy should be performed either within 3 days or beyond 3 months after primary surgery.
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Affiliation(s)
- Gabriel Glockzin
- Department of Surgery, University Medical Center Regensburg, Regensburg, 93042, Germany
| | - Matthias Hornung
- Department of Surgery, University Medical Center Regensburg, Regensburg, 93042, Germany
| | - Klaus Kienle
- Department of Surgery, University Medical Center Regensburg, Regensburg, 93042, Germany
| | - Katrin Thelen
- Department of Surgery, University Medical Center Regensburg, Regensburg, 93042, Germany
| | - Marita Boin
- Department of Surgery, Hospital Cham, Cham, Germany
| | - Andreas G Schreyer
- Department of Radiology, University Medical Center Regensburg, Regensburg, Germany
| | - Hamid R Lighvani
- Department of Nuclear Medicine, University Medical Center Regensburg, Regensburg, Germany
| | - Hans J Schlitt
- Department of Surgery, University Medical Center Regensburg, Regensburg, 93042, Germany
| | - Ayman Agha
- Department of Surgery, University Medical Center Regensburg, Regensburg, 93042, Germany.
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Taeger J, Moser C, Hellerbrand C, Mycielska ME, Glockzin G, Schlitt HJ, Geissler EK, Stoeltzing O, Lang SA. Targeting FGFR/PDGFR/VEGFR impairs tumor growth, angiogenesis, and metastasis by effects on tumor cells, endothelial cells, and pericytes in pancreatic cancer. Mol Cancer Ther 2011; 10:2157-67. [PMID: 21885862 DOI: 10.1158/1535-7163.mct-11-0312] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Activation of receptor tyrosine kinases, such as fibroblast growth factor receptor (FGFR), platelet-derived growth factor receptor (PDGFR), and VEGF receptor (VEGFR), has been implicated in tumor progression and metastasis in human pancreatic cancer. In this study, we investigated the effects of TKI258, a tyrosine kinase inhibitor to FGFR, PDGFR, and VEGFR on pancreatic cancer cell lines (HPAF-II, BxPC-3, MiaPaCa2, and L3.6pl), endothelial cells, and vascular smooth muscle cells (VSMC). Results showed that treatment with TKI258 impaired activation of signaling intermediates in pancreatic cancer cells, endothelial cells, and VSMCs, even upon stimulation with FGF-1, FGF-2, VEGF-A, and PDGF-B. Furthermore, blockade of FGFR/PDGFR/VEGFR reduced survivin expression and improved activity of gemcitabine in MiaPaCa2 pancreatic cancer cells. In addition, motility of cancer cells, endothelial cells, and VSMCs was reduced upon treatment with TKI258. In vivo, therapy with TKI258 led to dose-dependent inhibition of subcutaneous (HPAF-II) and orthotopic (L3.6pl) tumor growth. Immunohistochemical analysis revealed effects on tumor cell proliferation [bromodeoxyuridine (BrdUrd)] and tumor vascularization (CD31). Moreover, lymph node metastases were significantly reduced in the orthotopic tumor model when treatment was initiated early with TKI258 (30 mg/kg/d). In established tumors, TKI258 (30 mg/kg/d) led to significant growth delay and improved survival in subcutaneous and orthotopic models, respectively. These data provide evidence that targeting FGFR/PDFGR/VEGFR with TKI258 may be effective in human pancreatic cancer and warrants further clinical evaluation.
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Affiliation(s)
- Johannes Taeger
- Department of Surgery, University of Regensburg Medical Center, Franz-Josef-Strauss Allee 11, 93042 Regensburg, Germany
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20
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Glockzin G, Schlitt HJ, Piso P. Bidirectional intraperitoneal chemotherapy with oxaliplatin in the context of CRS and HIPEC in patients with peritoneal carcinomatosis. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.4_suppl.568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
568 Background: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) provide a promising therapeutic option for selected patients with peritoneal carcinomatosis. The use of oxaliplatin as an intraperitoneal cytostatic agent seems to further improve the efficacy of the combined treatment concept. Nevertheless, additional toxicity in comparison to mitomycin C and/or doxorubicin might be exspected. Methods: Between 02/2008 and 08/2010 40 patients underwent CRS and HIPEC with oxaliplatin at a concentration of 300 mg/sqm at the University Medical Center Regensburg. Thirty-five of these patients received bidirectional chemotherapy with additional intravenous application of 5FU/LV and 5 patients intraperitoneal oxaliplatin only. Perfusion time was 30 and 60 minutes, respectively. A matched-pair analysis was performed to compare IP oxaliplatin to our former standard HIPEC with mitomycin C and doxorubicin. Matching criteria were operating time, age and sex. Results: The mean operating time in the OX and the MMC group was 315 and 313 minutes, respectively. The mean age was 52 and 51 years, and 15 versus 16 patients were female, respectively. Median hospital stay was 15.5 days in the OX group and 17 days in the MMC group. The median stay on ICU was one day in both groups. The grade 3/4 morbidity rate was 42.5 % versus 37.5 % (p = 0.648). Five versus six patients had to be reoperated. Perioperative morbidity was 2.5 % versus 0 %. Main complications in the OX group were pleural effusion (5), thrombosis (2), cardiac arrhythmia (2), and abscess (2). In the MMC group postoperative morbidity was mainly caused by ileus (4), anastomotic leakage (3), pulmonary embolism (2), and wound infection (2). Conclusions: Our data suggest that the use of IP oxaliplatin in the context of CRS and HIPEC does not increase perioperative morbidity and/or mortality rate. Nevertheless, randomized controlled trials are required to determine the best intraperitoneal chemotherapeutic regimen regarding toxicity and oncological outcome. No significant financial relationships to disclose.
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Affiliation(s)
- G. Glockzin
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - H. J. Schlitt
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - P. Piso
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
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Piso P, Glockzin G, Schlitt HJ. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with peritoneal carcinomatosis arising from gastric cancer. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.4_suppl.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
132 Background: Peritoneal carcinomatosis is a common sign of advanced tumor stage or disease recurrence in patients with gastric cancer. The prognosis of these patients is poor. There is some evidence that CRS and HIPEC may improve the oncological outcome of a highly selected part of patients with peritoneal carcinomatosis arising from gastric cancer. Nevertheless, the use of CRS and HIPEC as an additional therapeutic option is still controversial. Methods: Between 01/2005 and 09/2009 16 out of 256 patients underwent CRS and HIPEC for peritoneal carcinomatosis arising from gastric cancer at the University of Regensburg Medical Center. The mean age of patients at the time of surgery was 52 years (range 32-69). Four patients were female (25%). The mean follow-up time was 16.3 months. Results: Thirteen patients (81.25%) underwent complete macroscopic cytoreduction (CC-0/1). HIPEC was performed in all patients. The median hospital stay was 19.5 days (range 8-44) and the median stay on ICU 1 day (range 0-14), respectively. The median operating time was 342 minutes (range 49- 510). The perioperative grade 3/4 morbidity rate was 37.5%. Postoperative complications were pneumonia (2), pancreatitis (2), pneumothorax (2), intraabdominal abscess (2), renal insufficiency (1), urine bladder dysfunction (1) and wound infection (1). There was no operative mortality in our series. The 1-year survival rate was 68.7%. The mean survival of the ten patients that died during follow-up was 14.1 months (range 3.4-44.8). Conclusions: In highly selected patients with gastric cancer and peritoneal carcinomatosis CRS and HIPEC may lead to prolonged survival rates. However, the therapy should be integrated in an interdisciplinary multimodality treatment concept. Further prospective randomized trials are required to determine the role of CRS and HIPEC in the treatment of patients with gastric cancer. No significant financial relationships to disclose.
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Affiliation(s)
- P. Piso
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - G. Glockzin
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - H. J. Schlitt
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
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Glockzin G, Renner P, Popp FC, Dahlke MH, von Breitenbuch P, Schlitt HJ, Piso P. Hepatobiliary procedures in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Ann Surg Oncol 2010; 18:1052-9. [PMID: 21046262 DOI: 10.1245/s10434-010-1415-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Indexed: 12/18/2022]
Abstract
BACKGROUND The long-term prognosis of patients with peritoneal malignancies has greatly improved since the introduction of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Nevertheless, CRS can be associated with high postoperative morbidity. In this retrospective study, we analyzed the influence of hepatobiliary surgery as part of CRS on postoperative short-term patient outcome. METHODS Between 2005 and 2008, a total of 63 (25%) of 252 patients with peritoneal surface malignancies undergoing CRS and HIPEC required hepatobiliary surgery. Liver resection was performed in 22, resection of Glisson capsule in 39, and bile duct resection in 2 patients. The mean age of the study population was 49.3 years. Thirty-four patients (54%) were women. RESULTS Complete macroscopic cytoreduction (CC-0/1) was reached in 59 patients (93.7%). The median hospital stay was 18 days. Twenty-two patients developed minor complications (35%), such as moderate fever, pain, or secondary wound healing. In 21 patients (33%), severe complications occurred, most commonly pancreatitis and abdominal abscess. Three patients (4.8%) developed a biliary leakage. Of these, 2 had to be reoperated. CONCLUSIONS In our experience, hepatobiliary procedures have to be performed in up to one-third of patients and are associated with a low rate of specific complications, such as biliary leakages.
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Affiliation(s)
- Gabriel Glockzin
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
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Agha A, Hornung M, Iesalnieks I, Glockzin G, Schlitt HJ. Single-Incision Retroperitoneoscopic Adrenalectomy and Single-Incision Laparoscopic Adrenalectomy. J Endourol 2010; 24:1765-70. [DOI: 10.1089/end.2010.0238] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Ayman Agha
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Matthias Hornung
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Igors Iesalnieks
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Gabriel Glockzin
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Hans J. Schlitt
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
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Abstract
Four endoscopic and four open accesses are available for the surgery of adrenal tumours. The decision to use one of the available techniques depends on tumour size, body mass index, previous abdominal surgery and the experience of the surgeon. Currently, the lateral laparoscopic and the dorsal retroperitoneoscopic approaches are most frequently used. Conventional surgery should be used if malignancy is suspected, especially for tumours larger than 6 cm. In individual cases, even tumours up to 10 cm can be operated laparoscopically if there is no suspicion of invasive growth or lymphatic metastases. Each surgeon should choose the most familiar access. The retroperitoneoscopic and laparoscopic accesses for benign adrenal tumours up to 6 cm are considered to be equivalent. The surgeon should also be able to approach adrenal tumours conventionally.
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Affiliation(s)
- A Agha
- Universitätsklinikum Regensburg, Klinik und Poliklinik für Chirurgie, Regensburg, Deutschland.
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25
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Piso P, Glockzin G, von Breitenbuch P, Popp FC, Dahlke MH, Schlitt HJ, Nissan A. Quality of life after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal surface malignancies. J Surg Oncol 2009; 100:317-20. [PMID: 19697438 DOI: 10.1002/jso.21327] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Pompiliu Piso
- University Medical Center Regensburg, Regensburg, Germany.
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Glockzin G, Ghali N, Lang SA, Schlitt HJ, Piso P. Results of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis from colorectal cancer. J Surg Oncol 2009; 100:306-10. [DOI: 10.1002/jso.21332] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Lang SA, Glockzin G, Dahlke MH, Popp FC, Agha A, Schlitt HJ, Piso P. [The techniques of peritonectomy and hyperthermic intraperitoneal chemotherapy]. Zentralbl Chir 2009; 134:443-9. [PMID: 19492282 DOI: 10.1055/s-0028-1098704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The treatment of peritoneal carcinomatosis represents a challenge in the therapy for gastrointestinal cancer. A multimodal approach with complete surgical cytoreduction and hyperthermic intraperitoneal chemotherapy can improve the prognosis in selected patients. Complete surgical cytoreduction, consisting of parietal and visceral peritonectomy, is a sophisticated procedure, frequently requiring multivisceral resections and should only be performed by experienced visceral surgeons. In addition, hyperthermic intraperitoneal chemotherapy is of some complexity. Furthermore, regarding the learning curve for this procedure, combined treatment should only be performed in specialised centres. Under optimal conditions, the therapy can be carried out with reasonable morbidity and mortality rates. Patients with peritoneal carcinomatosis should be evaluated by an interdisciplinary team concerning this multimodal therapy option and, if applicable, they should be referred to therapy within the framework of clinical studies.
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Affiliation(s)
- S A Lang
- Klinik und Poliklinik für Chirurgie, Uniklinik Regensburg, Franz-Josef-Strauss-Allee 11, Regensburg, Germany
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Piso P, Slowik P, Popp F, Dahlke MH, Glockzin G, Schlitt HJ. Safety of gastric resections during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis. Ann Surg Oncol 2009; 16:2188-94. [PMID: 19408049 DOI: 10.1245/s10434-009-0478-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2009] [Revised: 03/25/2009] [Accepted: 03/25/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cytoreductive surgery (CRS) including gastric resection combined with hyperthermic intraperitoneal chemotherapy (HIPEC) can improve the prognosis of selected patients with peritoneal surface malignancies. Perioperative morbidity of this aggressive treatment strategy is high; however, overall mortality can be low in specialized centers. The aim of this study was to assess the safety of gastric resections with anastomosis during CRS and HIPEC. METHODS Between 2005 and 2008, 204 patients underwent CRS and HIPEC at our tertiary referral centre. Of these, 37 procedures (male/female 24/13, median age 55 years) included gastric resections. The clinical data of all patients were introduced into a database and analyzed with respect to the morbidity associated with the gastric resections. RESULTS Of all patients included, 16 had pseudomyxoma peritonei, 11 gastric carcinoma, 4 ovarian carcinoma, 3 malignant peritoneal mesothelioma, and 3 colon carcinoma. Twenty-seven patients had previous surgery (n = 22) and/or systemic chemotherapy (n = 18). Fifteen total gastrectomies, 3 subtotal gastrectomies, 12 distal gastrectomies, and 7 gastric wedge resections were performed during CRS. The overall postoperative morbidity was 45%; main surgical complications were pancreatitis (n = 6), abdominal abscess (n = 4), bile leakage (n = 2), and digestive fistula (leakage of ileorectostomy and small bowel perforation) (n = 2). However, no complications occurred at the site of the esophageal anastomosis (n = 15), gastric anastomosis (n = 15) or gastric suture (n = 7). No patient died postoperatively during the hospitalization period. CONCLUSIONS CRS in combination with HIPEC is associated with high postoperative morbidity; however, anastomosis following total or subtotal gastrectomy is safe in experienced centers. No leakages related to gastric resections occurred in this high-risk patient group.
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Affiliation(s)
- Pompiliu Piso
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany.
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Agha A, Fürst A, Hierl J, Iesalnieks I, Glockzin G, Anthuber M, Jauch KW, Schlitt HJ. Laparoscopic surgery for rectal cancer: oncological results and clinical outcome of 225 patients. Surg Endosc 2008; 22:2229-37. [DOI: 10.1007/s00464-008-0028-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2007] [Revised: 03/22/2008] [Accepted: 04/10/2008] [Indexed: 12/14/2022]
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Agha A, Glockzin G, Ghali N, Iesalnieks I, Schlitt HJ. Surgical treatment of substernal goiter: An analysis of 59 patients. Surg Today 2008; 38:505-11. [DOI: 10.1007/s00595-007-3659-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2007] [Accepted: 08/13/2007] [Indexed: 11/29/2022]
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31
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Glockzin G, Ghali N, Lang SA, Agha A, Schlitt HJ, Piso P. [Peritoneal carcinomatosis. Surgical treatment, including hyperthermal intraperitoneal chemotherapy]. Chirurg 2008; 78:1100, 1102-6, 1108-10. [PMID: 17992490 DOI: 10.1007/s00104-007-1419-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Colorectal cancer is a common malignant disease with increasing incidence and a significant cause of death in cancer patients. More than 10% of patients with colorectal cancer show peritoneal carcinomatosis at initial diagnosis. Moreover, peritoneal metastasis is a common sign of recurrence. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are a new treatment strategy for highly selected patients with peritoneal carcinomatosis. Numerous studies show prolonged survival after CRS and HIPEC with acceptable morbidity and mortality rates. Accurate preoperative diagnostics and patient selection play a pivotal role in postoperative patient outcome. This promising treatment strategy is discussed regarding surgical technique, intraperitoneal chemotherapy, and patient outcome.
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Affiliation(s)
- G Glockzin
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum, Franz-Josef-Strauss-Allee 11, 93053, Regensburg
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Lang SA, Moser C, Gaumann A, Klein D, Glockzin G, Popp FC, Dahlke MH, Piso P, Schlitt HJ, Geissler EK, Stoeltzing O. Targeting heat shock protein 90 in pancreatic cancer impairs insulin-like growth factor-I receptor signaling, disrupts an interleukin-6/signal-transducer and activator of transcription 3/hypoxia-inducible factor-1alpha autocrine loop, and reduces orthotopic tumor growth. Clin Cancer Res 2008; 13:6459-68. [PMID: 17975158 DOI: 10.1158/1078-0432.ccr-07-1104] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Inhibitors of heat-shock protein 90 (Hsp90) may interfere with oncogenic signaling pathways, including Erk, Akt, and hypoxia-inducible factor-1alpha (HIF-1alpha). Because insulin-like growth factor-I receptor (IGF-IR) and signal transducer and activator of transcription 3 (STAT3) signaling pathways are implicated in the progression of pancreatic cancer, we hypothesized that blocking Hsp90 with geldanamycin derivates [17-allylamino-geldanamycin (17-AAG), 17-(dimethylaminoethylamino)-17-demethoxygeldanamycin (17-DMAG)] would impair IGF-I- and interleukin-6-mediated signaling and thus reduce pancreatic tumor growth and angiogenesis in vivo. EXPERIMENTAL DESIGN Human pancreatic cancer cells (HPAF-II, L3.6pl) were used for experiments. Changes in signaling pathway activation upon Hsp90 blockade were investigated by Western blotting. Effects of Hsp90 inhibition (17-AAG) on vascular endothelial growth factor were determined by ELISA and real-time PCR. Effects of 17-DMAG (25 mg/kg; thrice a week; i.p.) on tumor growth and vascularization were investigated in a s.c. xenograft model and in an orthotopic model of pancreatic cancer. RESULTS 17-AAG inhibited IGF-IR signaling by down-regulating IGF-IRbeta and directly impairing IGF-IR phosphorylation. Hypoxia- and IL-6-mediated activation of HIF-1alpha or STAT3/STAT5 were substantially inhibited by 17-AAG. Moreover, a novel IL-6/STAT3/HIF-1alpha autocrine loop was effectively disrupted by Hsp90 blockade. In vivo, 17-DMAG significantly reduced s.c. tumor growth and diminished STAT3 phosphorylation and IGF-IRbeta expression in tumor tissues. In an orthotopic model, pancreatic tumor growth and vascularization were both significantly reduced upon Hsp90 inhibition, as reflected by final tumor weights and CD31 staining, respectively. CONCLUSIONS Blocking Hsp90 disrupts IGF-I and IL-6-induced proangiogenic signaling cascades by targeting IGF-IR and STAT3 in pancreatic cancer, leading to significant growth-inhibitory effects. Therefore, we suggest that Hsp90 inhibitors could prove to be valuable in the treatment of pancreatic cancer.
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Affiliation(s)
- Sven A Lang
- Department of Surgery, University of Regensburg Medical Center, Regensburg, Germany
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Piso P, Ghali N, Dahlke M, Popp F, Lang S, Glockzin G, Breitenbuch PV, Agha A, Schlitt H, Ortmann O. Die intraoperative hypertherme intraperitoneale Chemotherapie als Therapieoption beim Ovarialkarzinom - Entwicklungen der letzten Jahre. Geburtshilfe Frauenheilkd 2007. [DOI: 10.1055/s-2007-989311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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34
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Bieler A, Mantwill K, Holzmüller R, Jürchott K, Kaszubiak A, Stärk S, Glockzin G, Lage H, Grosu AL, Gansbacher B, Holm PS. Impact of radiation therapy on the oncolytic adenovirus dl520: implications on the treatment of glioblastoma. Radiother Oncol 2007; 86:419-27. [PMID: 17967494 DOI: 10.1016/j.radonc.2007.10.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2007] [Revised: 09/14/2007] [Accepted: 10/04/2007] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE Viral oncolytic therapy is emerging as a new form of anticancer therapy and has shown promising preclinical results, especially in combination with radio- and chemotherapy. We recently reported that nuclear localization of the human transcription factor YB-1 in multidrug-resistant cells facilitates E1-independent adenoviral replication. The aim of this study was to evaluate the combined treatment of the conditionally-replicating adenovirus dl520 and radiotherapy in glioma cell lines in vitro and in human tumor xenografts. Furthermore, the dependency of YB-1 on dl520 replication was verified by shRNA directed down regulation of YB-1. METHODS AND MATERIAL Localization of YB-1 was determined by immunostaining. Glioma cell lines LN-18, U373 and U87 were infected with dl520. Induction of cytopathic effect (CPE), viral replication, viral yield and viral release were determined after viral infection, radiation therapy and the combination of both treatment modalities. The capacity of treatments alone or combined to induce tumor growth inhibition of subcutaneous U373 tumors was tested also in nude mice. RESULTS Quantitative real-time PCR demonstrated that the shRNA-mediated down regulation of YB-1 is leading to a dramatic decrease in adenoviral replication of dl520. Immunostaining analysis showed that the YB-1 protein was predominantly located in the cytoplasm in the perinuclear space and less abundant in the nucleus. After irradiation we found an increase of nuclear YB-1. The addition of radiotherapy increased the oncolytic effect of dl520 with enhanced viral replication, viral yield and viral release. The oncolytic activity of dl520 plus radiation inhibited the growth of subcutaneous U373 tumors in a xenograft mouse model. CONCLUSIONS Radiation mediated increase of nuclear YB-1 in glioma cells enhanced the oncolytic potential of adenovirus dl520.
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Affiliation(s)
- Alexa Bieler
- Institute of Experimental Oncology, Technical University of Munich, Germany
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35
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Lang SA, Klein D, Moser C, Gaumann A, Glockzin G, Dahlke MH, Dietmaier W, Bolder U, Schlitt HJ, Geissler EK, Stoeltzing O. Inhibition of heat shock protein 90 impairs epidermal growth factor-mediated signaling in gastric cancer cells and reduces tumor growth and vascularization in vivo. Mol Cancer Ther 2007; 6:1123-32. [PMID: 17363505 DOI: 10.1158/1535-7163.mct-06-0628] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Oncogenic signaling through activation of epidermal growth factor receptor (EGFR), HER-2, and hypoxia inducible-factor-1alpha (HIF-1alpha) has been implicated in gastric cancer growth and angiogenesis through up-regulation of vascular endothelial growth factor (VEGF). Recently, heat shock protein 90 (Hsp90) has been identified as a critical regulator of oncogenic protein stability, including EGFR, HER-2, and HIF-1alpha. We hypothesized that inhibition of Hsp90 impairs EGF- and hypoxia-mediated angiogenic signaling in gastric cancer cells and consequently inhibits angiogenesis and tumor growth. In vitro, the geldanamycin derivate 17-allylamino-17-demethoxygeldanamycin (17-AAG) led to marked reduction in constitutive and inducible activation of extracellular signal-regulated kinase 1/2, Akt, and signal transducer and activator of transcription 3 and decreased nuclear HIF-1alpha protein. In addition, EGFR and HER-2 were down-regulated after Hsp90 inhibition. With respect to regulation of angiogenic molecules, 17-AAG significantly reduced EGF-mediated VEGF secretion. Phosphorylation of focal adhesion kinase and paxillin were both abrogated by 17-AAG, which resulted in significant impairment of cancer cell motility. Interestingly, cytotoxic effects of 17-AAG in vitro were higher on cancer cells and gastric fibroblasts than on pericytes. In vivo, the water-soluble compound 17-dimethylaminoethylamino-17-demethoxygeldanamycin (17-DMAG; 25 mg/kg, thrice per week) significantly reduced s.c. xenografted tumor growth. By immunohistochemistry, 17-DMAG significantly reduced vessel area and numbers of proliferating tumor cells in sections. Furthermore, similar significant growth-inhibitory effects of 17-DMAG were achieved when administered as low-dose therapy (5 mg/kg, thrice per week). In conclusion, blocking Hsp90 disrupts multiple proangiogenic signaling pathways in gastric cancer cells and inhibits xenografted tumor growth in vivo. Hence, gastric cancer harbors attractive molecular targets for therapy with Hsp90 inhibitors, which could lead to improved efficacy of antineoplastic therapy regimens.
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MESH Headings
- Angiogenesis Inhibitors/therapeutic use
- Animals
- Benzoquinones/pharmacology
- Blood Vessels/drug effects
- Blood Vessels/growth & development
- Blood Vessels/metabolism
- Cell Hypoxia/drug effects
- Cell Line, Tumor/drug effects
- Cell Movement/drug effects
- Cell Proliferation/drug effects
- Cyclic AMP Response Element-Binding Protein/metabolism
- Enzyme-Linked Immunosorbent Assay
- Epidermal Growth Factor/metabolism
- ErbB Receptors/metabolism
- Extracellular Signal-Regulated MAP Kinases/metabolism
- Fibroblasts/drug effects
- Fibroblasts/metabolism
- HSP90 Heat-Shock Proteins/antagonists & inhibitors
- HSP90 Heat-Shock Proteins/metabolism
- Humans
- Hypoxia-Inducible Factor 1, alpha Subunit/metabolism
- Lactams, Macrocyclic/pharmacology
- Male
- Mice
- Mice, Inbred BALB C
- Mitogen-Activated Protein Kinases/metabolism
- Muscle, Smooth, Vascular/drug effects
- Muscle, Smooth, Vascular/metabolism
- Neovascularization, Pathologic/drug therapy
- Pericytes/drug effects
- Pericytes/metabolism
- Proto-Oncogene Proteins c-akt
- Receptor, ErbB-2/metabolism
- Signal Transduction/physiology
- Stomach Neoplasms/blood supply
- Stomach Neoplasms/metabolism
- Vascular Endothelial Growth Factor A/metabolism
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Affiliation(s)
- Sven A Lang
- Departments of Surgery and Surgical Oncology, University of Regensburg, Franz-Josef-Strauss Allee 11, 93042 Regensburg, Germany
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Agha A, Glockzin G, Woenckhaus M, Dietmaier W, Iesalnieks I, Schlitt HJ. Insular carcinomas of the thyroid exhibit poor prognosis and long-term survival in comparison to follicular and papillary T4 carcinomas. Langenbecks Arch Surg 2007; 392:671-7. [PMID: 17216284 DOI: 10.1007/s00423-006-0122-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2006] [Accepted: 11/03/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Insular thyroid carcinoma was described as a tumor with aggressive behavior, and patients usually present themselves with an advanced tumor stage. Whether the insular component is an independent factor for poor prognosis remains unclear. Therefore, in the present study, we compared the survival of patients with advanced insular, follicular, and papillary thyroid cancer. MATERIALS AND METHODS The clinical behavior of tumors in three groups of patients with T4 thyroid carcinoma--8 patients with insular, 11 patients with follicular, and 21 patients with papillary thyroid carcinomas--was compared. Disease-free survival and disease-specific death were analyzed statistically. Cox regression analysis was used to evaluate the influence of histotype and other prognostic factors. RESULTS At 3 years, survival was 37.5% (mean 26 months) among patients with insular thyroid carcinoma, 80% (mean 59 months) among those with follicular, and 89% (mean 126 months) among those with papillary thyroid carcinomas (p = 0.007). Disease-free survival in patients without initial distant metastasis was worst in patients with insular thyroid carcinoma (20%) compared to those with follicular (75%) and those with papillary thyroid carcinomas (71%). CONCLUSION Patients with advanced insular thyroid carcinoma have a poorer outcome in comparison to patients with similar advanced stage who have follicular or papillary thyroid carcinoma.
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Affiliation(s)
- Ayman Agha
- Department of Surgery, University of Regensburg Medical Center, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany.
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37
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Glockzin G, Schlitt HJ, Piso P. Zytoreduktive Chirurgie und hypertherme intraperitoneale Chemotherapie bei peritoneal metastasiertem Kolonkarzinom. Visc Med 2007. [DOI: 10.1159/000109411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Abstract
OBJECTIVE Clinically important, isolated metastases to the thyroid gland is a rare occurrence. Renal cell carcinoma (RCC) is the most common primary tumor site. We report on 8 cases of late onset metachronous thyroid metastases of RCC. DESIGN Eight patients presented with metachronous thyroid metastases at a median of 12 years (range 9-18 years) after nephrectomy for RCC. Two patients had simultaneous lung and lymph node metastases, respectively. Four patients had been previously operated for other metastases 1 to 5 years earlier, three of them due to pancreatic metastases. The leading symptom was neck enlargement in all but one case. MAIN OUTCOME Four total thyroidectomies, 3 subtotal resections, and 1 lobectomy were performed. Complete removal of metastases were achieved in all but one case. There was no postoperative morbidity. Six metastases were bilateral, two unilateral. The 4 year overall survival rate following metastasectomy was 53%, median survival from the date of nephrectomy was 21 years. CONCLUSION Long-term survival can be achieved after resection of isolated metachronous RCC metastases to the thyroid gland. Total thyroidectomy is not required, unless it is necessary for complete metastasectomy.
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Bieler A, Mantwill K, Dravits T, Bernshausen A, Glockzin G, Köhler-Vargas N, Lage H, Gansbacher B, Holm PS. Novel three-pronged strategy to enhance cancer cell killing in glioblastoma cell lines: histone deacetylase inhibitor, chemotherapy, and oncolytic adenovirus dl520. Hum Gene Ther 2006; 17:55-70. [PMID: 16409125 DOI: 10.1089/hum.2006.17.55] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Resistance to radiation and chemotherapy remains an obstacle to the treatment of brain tumors. We have demonstrated that the replication-deficient adenovirus d1520, which lacks the E1A 13S protein, replicates efficiently and exhibits oncolytic potential in multidrug-resistant cells with nuclear localization of the human transcription factor YB-1. However, besides others, key factors regarding oncolytic virotherapy are limited tumor transduction rate and low replication efficiency. The objective of this study was to determine whether the chemotherapeutic agent irinotecan, by enhancing nuclear localization of YB-1, and the histone deacetylase inhibitor trichostatin A, by upregulating coxsackievirus-adenovirus receptor (CAR) expression, could augment replication of and cell lysis by adenovirus dl520 in glioblastomas in vitro. We found that trichostatin A upregulated CAR expression and that irinotecan caused increased nuclear localization of YB-1 in both glioblastoma cell lines. Irinotecan alone, and trichostatin A alone, enhanced replication of and cell lysis by dl520. Importantly, when combining both agents, the replication efficiency (maximum, 27-fold) and induction of cytopathic effect (maximum, 3.8-fold) of dl520 were further augmented significantly. These results support the hypothesis that the enhanced oncolytic effect of dl520, after incubation with chemotherapeutic agents, is mediated by an increased accumulation of YB-1 in the nucleus (due to irinotecan) and by upregulation of CAR (due to trichostatin A). Thus, therapy combining virotherapy, chemotherapy, and histone deacetylase inhibitor treatment is a novel approach to enhance the oncolytic efficacy of dl520.
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Affiliation(s)
- Alexa Bieler
- Institute of Experimental Oncology, Technical University of Munich, Klinikum Rechts-der-Isar, 81675 Munich, Germany
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40
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Schnitzbauer AA, Loss M, Hornung M, Glockzin G, Mantouvalou L, Krüger B, Krämer BK, Schlitt HJ, Obed A. Mini-incision for strictly retroperitoneal nephrectomy in living kidney donation vs flank incision. Nephrol Dial Transplant 2006; 21:2948-52. [PMID: 16891649 DOI: 10.1093/ndt/gfl158] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Mini-incision donor nephrectomies (MIDNs) were established during the last decade, as an alternative to traditional open donor nephrectomy (ODN) via flank incision. In this study, we investigated intra-operative and post-operative data on outcome following MIDN in comparison with ODN data. METHODS Data of 70 living kidney donations, performed at the University of Regensburg Medical Center since 1996, were evaluated. Donor operation was performed as either strictly retroperitoneal MIDN (n = 34) or as traditional ODN (n = 36) via flank incision. Total operation time, warm ischaemia time (WIT), perioperative pain-medication usage and creatinine levels as well as length of hospital stay, return to complete enteral nutrition and regular digestion were evaluated retrospectively. RESULTS Total operation times were similar in MIDN, n = 34 (132 +/- 26 min) and in ODN, n = 36 (140 +/- 37 min) (P = 0.424). WIT was also similar in both: MIDN (0.9 +/- 0.4 min) and ODN (0.9 +/- 0.4 min) (P = 0.568). The requirement for post-operative opioids in morphine equivalent doses was significantly lower in MIDN (8.4 +/- 16 mg) compared with ODN (44 +/- 57 mg) (P = 0.001). Additional application of non-opioids (metamizole) (MIDN: 4.8 +/- 6.3 g, ODN: 3.4 +/- 3.9 g) and non-steroidal antirheumatic (NSAR) (diclofenac) (MIDN: 322 +/- 361 mg, ODN: 247 +/- 474 mg) revealed no significant differences between the groups. The hospital stay was 4.9 +/- 1.4 days in MIDN which was significantly shorter than that in ODN (9.3 +/- 3.3 days) (P = 0.001). Patients achieved fully independent mobility earlier in MIDN than in ODN (P = 0.934). Start of enteral nutrition with fluids was significantly quicker in MIDN (1.9 +/- 7 h) compared with ODN (12 +/- 13 h) (P = 0.05). Full enteral nutrition was accomplished significantly earlier in MIDN (1.6 +/- 0.8 days) (P = 0.023). Return to normal digestion revealed no significant differences between groups. Serum creatinine levels of all kidney donors were in the normal range (66 +/- 18 micromol/l) one day before nephrectomy, increased on day 1 after surgery (119 micromol/l +/- 31 micromol/l) and were stable on day 3 (115 micromol/l +/- 30 micromol/l) without significant differences. CONCLUSION Strictly, retroperitoneal MIDN in living kidney donation is a fast and safe method for the procurement of a living donor graft, giving the patient a significantly shorter period of recovery, and thus is an attractive and recommendable alternative to traditional ODN procedures.
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Affiliation(s)
- A A Schnitzbauer
- University of Regensburg Medical Center, Department of Surgery, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany.
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41
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Iesalnieks I, Woenckhaus M, Glockzin G, Schlitt HJ, Agha A. Schilddrüsenmetastasen eines Nierenzellkarzinoms - drei Fallvorstellungen und Übersicht der Literatur. Zentralbl Chir 2006; 131:235-9. [PMID: 16739065 DOI: 10.1055/s-2006-933468] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Clinically significant, solitary metastasis to the thyroid gland is a rare occurrence. The clear cell carcinoma of the kidney (RCC) is the most common primary tumor site. Late recurrence is a notable feature of renal carcinoma. Solitary metastases in the thyroid gland occur as late as 100-120 months from the date of nephrectomy. There is a clear survival benefit in selected cases if surgical approach to the thyroid metastases is chosen. In those patients who have undergone complete resection, 5-year-survival-rates of 50 % have been reported. We describe 3 cases of surgically treated thyroid metastases of RCC, and review the literature.
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Affiliation(s)
- I Iesalnieks
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg.
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Glockzin G, Mantwill K, Jurchott K, Bernshausen A, Ladhoff A, Royer HD, Gansbacher B, Holm PS. Characterization of the recombinant adenovirus vector AdYB-1: implications for oncolytic vector development. J Virol 2006; 80:3904-11. [PMID: 16571807 PMCID: PMC1440461 DOI: 10.1128/jvi.80.8.3904-3911.2006] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Conditionally replicating adenoviruses are a promising new modality for the treatment of cancer. However, early clinical trials demonstrate that the efficacy of current vectors is limited. Interestingly, DNA replication and production of viral particles do not always correlate with virus-mediated cell lysis and virus release depending on the vector utilized for infection. However, we have previously reported that nuclear accumulation of the human transcription factor YB-1 by regulating the adenoviral E2 late promoter facilitates viral DNA replication of E1-deleted adenovirus vectors which are widely used for cancer gene therapy. Here we report the promotion of virus-mediated cell killing as a new function of the human transcription factor YB-1. In contrast to the E1A-deleted vector dl312 the first-generation adenovirus vector AdYB-1, which overexpresses YB-1 under cytomegalovirus promoter control, led to necrosis-like cell death, virus production, and viral release after infection of A549 and U2OS tumor cell lines. Our data suggest that the integration of YB-1 in oncolytic adenoviruses is a promising strategy for developing oncolytic vectors with enhanced potency against different malignancies.
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Affiliation(s)
- Gabriel Glockzin
- Institut fuer Experimentelle Onkologie und Therapieforschung, Technische Universitaet Muenchen, Klinikum rechts der Isar, Ismaninger Str. 22, 81675 Munich, Germany
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Tsui TY, Lau CK, Ma J, Glockzin G, Obed A, Schlitt HJ, Fan ST. Adeno-associated virus-mediated heme oxygenase-1 gene transfer suppresses the progression of micronodular cirrhosis in rats. World J Gastroenterol 2006; 12:2016-23. [PMID: 16610050 PMCID: PMC4087678 DOI: 10.3748/wjg.v12.i13.2016] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To test the hypothesis that enhancement of the activity of heme oxygenase can interfere with processes of fibrogenesis associated with recurrent liver injury, we investigated the therapeutic potential of over-expression of heme oxygense-1 in a CCl4-induced micronodular cirrhosis model.
METHODS: Recombinant adeno-associated viruses carrying rat HO-1 or GFP gene were generated. 1×1012 vg of adeno-associated viruses were administered through portal injection at the time of the induction of liver fibrosis.
RESULTS: Conditioning the rat liver with over-expression of HO-1 by rAAV/HO-1 significantly increased the HO enzymatic activities in a stable manner. The development of micronodular cirrhosis was significantly inhibited in rAAV/HO-1-transduced animals as compared to controls. Portal hypertension was markedly diminished in rAAV/HO-1-transduced animals as compared to controls, whereas there are no significant changes in systolic blood pressure. This finding was accompanied with improved liver biochemistry, less infiltrating macrophages and less activated hepatic stellate cells (HSCs) in rAAV/HO-1-transduced livers.
CONCLUSIONS: Enhancement of HO activity in the livers suppresses the development of cirrhosis.
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Affiliation(s)
- Tung-Yu Tsui
- Department of Surgery, Center for the Study of Liver Disease, the University of Hong Kong, Pokfulam, Hong Kong.
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Bieler A, Mantwill K, Dravits T, Bernshausen A, Glockzin G, Kohler-Vargas N, Lage H, Gansbacher B, Holm PS. Novel Three-Pronged Strategy to Enhance Cancer Cell Killing in Glioblastoma Cell Lines: Histone Deacetylase Inhibitor, Chemotherapy, and Oncolytic Adenovirus dl520. Hum Gene Ther 2005. [DOI: 10.1089/hum.2005.17.ft-161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Bieler A, Mantwill K, Dravits T, Bernshausen A, Glockzin G, Kohler-Vargas N, Lage H, Gansbacher B, Holm PS. Novel Three-Pronged Strategy to Enhance Cancer Cell Killing in Glioblastoma Cell Lines: Histone Deacetylase Inhibitor, Chemotherapy, and Oncolytic Adenovirus dl520. Hum Gene Ther 2005. [DOI: 10.1089/hum.2005.17.ft-158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Holm PS, Lage H, Bergmann S, Jürchott K, Glockzin G, Bernshausen A, Mantwill K, Ladhoff A, Wichert A, Mymryk JS, Ritter T, Dietel M, Gänsbacher B, Royer HD. Multidrug-resistant cancer cells facilitate E1-independent adenoviral replication: impact for cancer gene therapy. Cancer Res 2004; 64:322-8. [PMID: 14729641 DOI: 10.1158/0008-5472.can-0482-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Resistance to chemotherapy is responsible for a failure of current treatment regimens in cancer patients. We have reported previously that the Y-box protein YB-1 regulates expression of the P-glycoprotein gene mdr1, which plays a major role in the development of a multidrug resistant-tumor phenotype. YB-1 predicts drug resistance and patient outcome in breast cancer. Thus, YB-1 is a promising target for new therapeutic approaches to defeat multidrug resistance. In drug-resistant cancer cells and in adenovirus-infected cells YB-1 is found in the nucleus. Nuclear accumulation of YB-1 in adenovirus-infected cells is a function of the E1 region, and we have shown that YB-1 facilitates adenovirus replication. Here we report that E1A-deleted or mutant adenovirus vectors, such as Ad312 and Ad520, replicate efficiently in multidrug-resistant (MDR) cancer cells and induce an adenovirus cytopathic effect resulting in host cell lysis. Thus, replication-defective adenoviruses are a previously unrecognized vector system for a selective elimination of MDR cancer cells. Our work forms the basis for the development of novel oncolytic adenovirus vectors for the treatment of MDR malignant diseases in the clinical setting.
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Affiliation(s)
- Per S Holm
- Institut für Experimentelle Onkologie und Therapieforschung, Technische Universität München, Klinikum Rechts der Isar, München, Germany.
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