Effects of the short stitch technique for midline abdominal closure on incisional hernia (ESTOIH): randomized clinical trial

BACKGROUND

Incisional hernia remains a frequent problem after midline laparotomy. This study compared a short stitch to standard loop closure using an ultra-long-term absorbent elastic suture material.

METHODS

A prospective, multicentre, parallel-group, double-blind, randomized, controlled superiority trial was designed for the elective setting. Adult patients were randomly assigned by computer-generated sequence to fascial closure using a short stitch (5 to 8 mm every 5 mm, USP 2-0, single thread HR 26 mm needle) or long stitch technique (10 mm every 10 mm, USP 1, double loop, HR 48 mm needle) with a poly-4-hydroxybutyrate-based suture material (Monomax®). Incisional hernia assessed by ultrasound 1 year after surgery was the primary outcome.

RESULTS

The trial randomized 425 patients to short (n = 215) or long stitch technique (n = 210) of whom 414 (97.4 per cent) completed 1 year of follow-up. In the short stitch group, the fascia was closed with more stitches (46 (12 s.d.) versus 25 (7 s.d.); P < 0.001) and higher suture-to-wound length ratio (5.3 (2.2 s.d.) versus 4.0 (1.3 s.d.); P < 0.001). At 1 year, seven of 210 (3.3 per cent) patients in the short and 13 of 204 (6.4 per cent) patients in the long stitch group developed incisional hernia (odds ratio 1.97, 95 per cent confidence interval 0.77 to 5.05; P = 0.173).

CONCLUSION

The 1-year incisional hernia development was relatively low with clinical but not statistical difference between short and long stitches. Registration number: NCT01965249 (http://www.clinicaltrials.gov).

PD-1 inhibition in patient derived tissue cultures of human gastric and gastroesophageal adenocarcinoma

Emerging immunotherapies quest for better patient stratification in cancer treatment decisions. Moderate response rates of PD-1 inhibition in gastric and esophagogastric junction cancers urge for meaningful human model systems that allow for investigating immune responses ex vivo. Here, the standardized patient-derived tissue culture (PDTC) model was applied to investigate tumor response to the PD-1 inhibitor Nivolumab and the CD3/CD28 t-lymphocyte activator ImmunoCult^TM. Resident t-lymphocytes, tumor proliferation and apoptosis, as well as bulk gene expression data were analyzed after 72 h of PD-1 inhibition either as monotherapy or combined with Oxaliplatin or ImmunoCult^TM. Individual responses to PD-1 inhibition were found ex vivo and combination with chemotherapy or t-lymphocyte activation led to enhanced antitumoral effects in PDTCs. T-lymphocyte activation as well as the addition of pre-cultured peripheral blood mononuclear cells improved PDTC for studying t-lymphocyte and tumor cell communication. These data support the potential of PDTC to investigate immunotherapy ex vivo in gastric and esophagogastric junction cancer.

Effects of the short-stitch technique for midline abdominal closure: short-term results from the randomised-controlled ESTOIH trial

Purpose

The short-stitch technique for midline laparotomy closure has been shown to reduce hernia rates, but long stitches remain the standard of care and the effect of the short-stitch technique on short-term results is not well known. The aim of this study was to compare the two techniques, using an ultra-long-term absorbable elastic suture material.

Methods

Following elective midline laparotomy, 425 patients in 9 centres were randomised to receive wound closure using the short-stitch (USP 2-0 single thread, n = 215) or long-stitch (USP 1 double loop, n = 210) technique with a poly-4-hydroxybutyrate-based suture material (Monomax^®). Here, we report short-term surgical outcomes.

Results

At 30 (+10) days postoperatively, 3 (1.40%) of 215 patients in the short-stitch group and 10 (4.76%) of 210 patients in the long-stitch group had developed burst abdomen [OR 0.2830 (0.0768–1.0433), p = 0.0513]. Ruptured suture, seroma and hematoma and other wound healing disorders occurred in small numbers without differences between groups. In a planned Cox proportional hazard model for burst abdomen, the short-stitch group had a significantly lower risk [HR 0.1783 (0.0379–0.6617), p = 0.0115].

Conclusions

Although this trial revealed no significant difference in short-term results between the short-stitch and long-stitch techniques for closure of midline laparotomy, a trend towards a lower rate of burst abdomen in the short-stitch group suggests a possible advantage of the short-stitch technique.

Trial registry

NCT01965249, registered October 18, 2013.

Hepatic Arterial Infusion Chemotherapy for Liver Metastases from Gastric Cancer: An Analysis in Western Patients

Aims and background

The advantage of administering chemotherapy by hepatic arterial infusion is the achievement of high drug concentrations in the liver. Oxaliplatin, irinotecan and 5-flourouracil are active agents in advanced gastric cancer. Therefore a retrospective analysis was performed to investigate the effects of these drugs administered by hepatic arterial infusion in heavily pretreated gastric cancer patients with predominant hepatic metastases. Very limited data about hepatic arterial infusion exist in western gastric cancer patients.

Methods

Seven patients with advanced gastric cancer were included in the retrospective analysis. All patients had proven progressive disease prior to initiation of hepatic arterial infusion. All had an ECOG performance status of ≤2 and had received at least two previous systemic chemotherapy regimens, including the combination of cisplatin/5-fluorouracil. Patients were given chemotherapy by hepatic arterial infusion: 5-fluorouracil, 600 mg/m2, together with folinic acid, 300 mg/m2/2 h, followed by oxaliplatin, 85 mg/m2/2 h, every 2 weeks.

Results

Fifty-four cycles of hepatic arterial infusion (range, 2–21) with a median treatment duration of 6 cycles were administered in 7 patients. The treatment was feasible and safe, no grade 3–4 toxicity was observed. One patient showed stabilization of liver metastases over 7 months. In 6 of the 7 patients there was radiologically proven progressive disease after a median treatment time of 10 weeks.

Conclusions

Chemotherapy by hepatic arterial infusion is modestly effective in heavily pretreated gastric cancer patients. Hepatic arterial infusion has a very favorable toxicity profile and can be safely administered even in elderly patients. It might be an additional therapeutic option and should be further investigated. The literature on hepatic arterial infusion in gastric cancer patients is reviewed. Free full text available at www.tumorionline.it

Organotypic slice cultures of human gastric and esophagogastric junction cancer

Gastric and esophagogastric junction cancers are heterogeneous and aggressive tumors with an unpredictable response to cytotoxic treatment. New methods allowing for the analysis of drug resistance are needed. Here, we describe a novel technique by which human tumor specimens can be cultured ex vivo, preserving parts of the natural cancer microenvironment. Using a tissue chopper, fresh surgical tissue samples were cut in 400 μm slices and cultivated in 6-well plates for up to 6 days. The slices were processed for routine histopathology and immunohistochemistry. Cytokeratin stains (CK8, AE1/3) were applied for determining tumor cellularity, Ki-67 for proliferation, and cleaved caspase-3 staining for apoptosis. The slices were analyzed under naive conditions and following 2-4 days in vitro exposure to 5-FU and cisplatin. The slice culture technology allowed for a good preservation of tissue morphology and tumor cell integrity during the culture period. After chemotherapy exposure, a loss of tumor cellularity and an increase in apoptosis were observed. Drug sensitivity of the tumors could be assessed. Organotypic slice cultures of gastric and esophagogastric junction cancers were successfully established. Cytotoxic drug effects could be monitored. They may be used to examine mechanisms of drug resistance in human tissue and may provide a unique and powerful ex vivo platform for the prediction of treatment response.

Organotypic slice cultures of human gastric cancer (GC) and esophagogastric junction adenocarcinoma (AEG): A new technology to study treatment response, resistance, and tumor heterogeneity

76

Background: GC and AEG have an unpredictable response to cytotoxic treatment and a poor prognosis. There is an urgent need for new research methods allowing for the determination of chemotherapy sensitivities, the analysis of resistance mechanisms and tumor heterogeneity. Here, we describe a novel technique extending our recent findings in other tumors (Gerlach et al. 2014; Merz et al. 2013), by which cancer specimens can be cultured in vitro and maintained in their natural micro-environment. Methods: Using a tissue chopper, fresh surgical and endoscopic tissue samples from GC and AEG were cut in 400 µm thick slices and cultivated in 6-well plates for up to 6 days. The slices were then fixed, embedded in paraffin and cut for routine histopathology and immunohistochemistry. Cytokeratin stains (CK8 and AE1/3) were used for determining tumor cellularity, ki-67 for proliferation, and cleaved caspase 3 staining for apoptosis. The slices were examined under naïve condition and following in-vitro exposure to 5-FU, cisplatin or docetaxel over a period of 2-4 days. Results: GC and AEG slice cultures from resection specimens (n=14) and endoscopic biopsies (n=17) revealed a good preservation of tissue morphology and tumor cell integrity during the culture period in most cases. The stroma and the tumor cellularity remained stable over at least 4 days, proving the viability of cancer in slice cultures. The amount of sampled tissue from endoscopic biopsies was identified as a critical determinant for the feasibility of slice cultures. During treatment of cultures with chemotherapy, a significant loss of tumor cellularity and an increase of apoptotic cells were observed, although a systematic and reproducible read-out still needs to be established. Conclusions: Slice cultures of GC and AEG were successfully established. They can be expected to provide a unique and powerful in vitro platform for the determination of sensitivities of a given tumor towards chemotherapy, to examine mechanisms of drug-resistance and to analyze tumor heterogeneity in patient samples.

Unravelling the mechanism of lithium insertion into and extraction from trirutile-type LiNiFeF6 cathode material for Li-ion batteries

For possible future application as cathode material in lithium ion batteries, the lithium insertion mechanism of trirutile-type LiNiFeF₆ was investigated.

Neutron and synchrotron probes in the development of Co–Re-based alloys for next generation gas turbines with an emphasis on the influence of boron additives

Nickel-based superalloys are the materials of choice in the hot section of current gas turbines, but they are reaching temperature limits constrained by their melting temperature range. Co–Re alloy development was prompted by a search for new materials for future gas turbines, where the temperature of application will be considerably higher. Addition of the very high melting point refractory metal Re to Co can increase the melting range of Co alloys to much higher temperatures than the commercial Co alloys in use today. The alloy development strategy is first discussed very briefly. In this program, model ternary and quaternary compositions were studied in order to develop a basic understanding of the alloy system.In situneutron and synchrotron measurements (small and wide angle) at high temperatures were extensively used for this purpose and some selected results from thein situmeasurements are presented. In particular, the effect of boron doping in Co–Re–Cr alloys and the stability of the TaC precipitates at high temperatures were investigated. A fine dispersion of TaC precipitates strengthens some Co–Re alloys, and their stability at the application temperature is critical for the long-term creep properties.

Einwirkung verschiedener Wasserstoff- und Kohlensäureionenkonzentrationen auf die Erythrocytenmembran

1. Erythrocytenstromata. die durch Hämolyse mittels saurer hypotonischer Pufferlösungen gewonnen werden, sind bei 2500 g zentrifugierbar, Stromata, die durch Hämolyse mittels neutraler oder alkalischer hypotonischer Pufferlösungen gewonnen werden, sind erst bei 13 000—15 000 g zentrifugierbar.

2. Die schwer zentrifugierbaren Schatten lassen sich durch mehrfaches „pH-Schaukeln“ allmählich irreversibel in den leicht zentrifugierbaren Zustand überführen. Es muß deshalb angenommen werden, daß der schwer zentrifugierbare Zustand der labilere ist, und daher dem nativen näher steht.

3. An einer Reihe von Hämolyseversuchen mit hypotonischen Lösungen verschiedener H-Ionenkonzentrationen und verschiedener Ionenarten wird gezeigt, daß die Anwesenheit von Carbonationen im Augenblick der Hämolyse zu Teilhämolysen eines Teils der Erythrocyten führen. Das hierbei zurückbleibende Resthämoglobin läßt sich durch osmotische Behandlungsmethoden nur zum geringen Teil aus den Schatten entfernen.

4. Hämolyse mit carbonationenarmen Lösungen dagegen führt zu Schatten, die nach mehrfachem osmotischem Schaukeln mit Fleisch scher Lösung und m/100-Phosphatpuffer (pH 8,2) extrem hämoglobinarm sind. Der Hämoglobingehalt der Trockensubstanz beträgt höchstens 0,05%.

5. Die Bedeutung dieser Ergebnisse für unsere Kenntnis der Erythrocytenmembran wird besprochen.

Impact of pathologic complete response on disease-free survival in patients with esophagogastric adenocarcinoma receiving preoperative docetaxel-based chemotherapy

BACKGROUND

The aim of this study was to evaluate the impact of pathologic complete response (pCR) on outcome in patients with gastric or esophagogastric junction (EGJ) adenocarcinoma after neoadjuvant docetaxel/platin/fluoropyrimidine-based chemotherapy.

PATIENTS AND METHODS

Patients received at least one cycle of chemotherapy for potentially operable disease. Pretreatment clinicopathologic factors and pCR were investigated. Disease-free survival (DFS), overall survival (OS) and tumor-related death were correlated with pCR.

RESULTS

One hundred twenty patients were included in this analysis. Eighteen patients (15%) achieved a pCR. Tumor localization in the EGJ was identified as the only significant predictor of pCR (P = 0.019). Median follow-up was 41.1 months. Median DFS and OS for all patients were 24.1 and 48.6 months, respectively. Median DFS for patients with a pCR was not reached versus 22.1 months non-pCR patients (hazard ratio, HR 0.38; 3-year DFS: 71.8% and 37.7%, respectively, P = 0.018). While OS was not significantly different, the risk for tumor-related death was significantly lower for pCR patients compared with non-pCR patients (3-year cumulative incidences of 6.4% and 45.4%, respectively, P = 0.009).

CONCLUSION

A pCR following preoperative docetaxel/platin/fluoropyrimidine indicates favorable outcome in patients with gastric or EGJ adenocarcinoma. Tumor location in the EGJ is associated with a higher pCR rate.

Medikamentöse Therapie der Peritonealkarzinose

<b><i>Hintergrund:</i></b> Die Behandlung der Peritonealkarzinose ist eine interdisziplinäre medizinische Herausforderung. Betreffend der medikamentösen Therapie fehlt bislang eine Standardisierung. <b><i>Methode:</i></b> Relevante Artikel zum Thema Peritonealkarzinose aus den Datenbanken der U.S. National Library of Medicine (PubMed) sowie der Kongressregister der American Society of Clinical Oncology und der European Society of Medical Oncology wurden durchsucht. Die Bedeutung der Berichte für die klinische Praxis wurde zwischen den Autoren diskutiert und interdisziplinär abgestimmt. Es wurden praxisnahe Folgerungen und Empfehlungen abgeleitet. <b><i>Ergebnisse:</i></b> PubMed weist eine ansteigende Zahl an Publikationen zum Thema Peritonealkarzinose auf. In 2012 wurden 563 Arbeiten unter dem Stichwort abgelegt. Die medikamentöse Therapie der Peritonealkarzinose ist ein Teil der multimodalen Behandlung, zu der die lokalen chirurgischen und physikalischen Therapiemaßnahmen zählen. Die Auswahl der Chemotherapeutika richtet sich nach der entsprechenden malignen Grunderkrankung. Aktuelle zielgerichtete Ansätze wie die anti-angiogene Therapie und die gegen das epitheliale Zelladhäsionsmolekül (EpCAM) gerichtete Immuntherapie ergänzen neuerdings das Behandlungsspektrum bei Peritonealkarzinose und malignem Aszites. <b><i>Schlussfolgerungen:</i></b> Die medikamentöse Behandlung der Peritonealkarzinose bleibt eine medizinische Herausforderung. Die zunehmende Zahl an Publikationen und Studien auf dem Gebiet lässt aber mittlerweile mehr evidenzbasierte Entscheidungen zu. Die interdisziplinäre Abstimmung eines individuellen Behandlungskonzepts bleibt bis auf Weiteres der Goldstandard auch für die medikamentöse Therapie der Peritonealkarzinose.

Perioperative chemotherapy with docetaxel, cisplatin and capecitabine (DCX) in gastro-oesophageal adenocarcinoma: a phase II study of the Arbeitsgemeinschaft Internistische Onkologie (AIO){dagger}

BACKGROUND

This prospective multicentre phase II trial assessed the feasibility and efficacy of perioperative chemotherapy with docetaxel, cisplatin and capecitabine (DCX) in patients with gastro-oesophageal adenocarcinoma.

METHODS

Patients with curatively resectable adenocarcinoma of the stomach, the gastro-oesophageal junction or the lower third of the oesophagus were enrolled. Patients received docetaxel 75 mg/m(2) plus cisplatin 60 mg/m(2) (day 1), followed by oral capecitabine 1875 mg/m(2) divided into two doses (days 1-14) every 3 weeks. There were three cycles preoperatively and three cycles postoperatively. The primary end point was the R0 resection rate.

RESULTS

Fifty-one patients were recruited and assessed for feasibility and efficacy. 94.1% of patients received all three planned cycles preoperatively, and 52.9% received three cycles postoperatively. The R0 resection rate was 90.2%. 13.7% of patients showed complete pathological remission (pCR). Toxicity was acceptably tolerable. Without prophylactic granulocyte colony-stimulating factor administration, neutropenic fever developed in 21.5% of patients preoperatively (grade 3 or 4) and in 11.1% of patients postoperatively.

CONCLUSIONS

DCX is a safe and feasible perioperative regimen in the treatment of gastro-oesophageal adenocarcinoma with a high percentage of cycles delivered pre- and postoperatively, compared with standard practice. The high efficacy in terms of R0 resection rate and pCR is very promising.

Irrelevance of microsatellite instability in the epidemiology of sporadic pancreatic ductal adenocarcinoma

BACKGROUND AND AIMS

Pancreatic cancer risk is increased in Lynch syndrome (LS) patients with mismatch repair gene defects predisposing to colonic and extracolonic cancers with microsatellite instability (MSI). However, the frequency of MSI pancreatic cancers has never been ascertained in consecutive, unselected clinical series, and their contribution to the sporadic and inherited burden of pancreatic cancer remains to be established. Aims of the study were to determine the prevalence of MSI in surgically resected pancreatic cancers in a multicentric, retrospective study, and to assess the occurrence of pancreatic cancer in LS.

METHODS

MS-status was screened by a panel of 5 mononucleotide repeats (Bat26, Bat25, NR-21, NR-24 and NR-27) in 338 consecutive pancreatic ductal adenocarcinoma (PDAC), resected at two Italian and one German referral centres. The personal history of pancreatic cancer was assessed in an independent set of 58 probands with LS and in 138 first degree relatives who had cancers.

RESULTS

Only one PDAC (0.3%) showed MSI. This was a medullary type cancer, with hMLH1-deficiency, and no identified germ-line mutation but methylation of hMLH1. Pancreatic cancer occurred in 5 (2.5%) LS patients. Histological sampling was available for 2 cases, revealing PDAC in one case and an ampullary cancer in the other one.

CONCLUSIONS

MSI prevalence is negligible in sporadic, resected PDAC. Differently, the prevalence of pancreatic cancer is 2.5% in LS patients, and cancers other than PDAC may be encountered in this setting. Surveillance for pancreatic cancer should be advised in LS mutation carriers at referral centers.

[Creation of centres in high-volume hospitals -- promotor of communication]

The number of patients with a diagnosis of cancer is alarming: according to new figures from the Robert Koch Institute about 435 000 patients are diagnosed annually in Germany. 210 000 patients die annually of this diagnosis. Even if no significant progress in prevention has been achieved, in 2020 about 25 % more cases will be diagnosed. In the last two decades it has become established that an interdisciplinary treatment of tumour patients is necessary because the variety of different treatment options depending on an individual person cannot be mastered by one physician. The goal of the centres and certification is to establish a very concentrated expertise in large case numbers and quality-assured transparent treatment. The central requirement of a maximum-care centre is thus to enable communication under appropriate conditions. Promoting not only the space requirements, centre must also develop a treatment corridor and is responsible for further education. Additionally an oncology centre has a goal in communications, namely, to offer a treatment option for all patients in each stage of the disease, and to incorporate cancer patients in clinical trials.

Survival advantage for irinotecan versus best supportive care as second-line chemotherapy in gastric cancer--a randomised phase III study of the Arbeitsgemeinschaft Internistische Onkologie (AIO)

BACKGROUND

The value of second-line therapy for metastatic gastric cancer is unclear. So far there are no randomised phase III data comparing second-line chemotherapy to best supportive care (BSC). In this prospective, multicenter, open label, randomised phase III study we compared irinotecan to BSC to evaluate the impact on survival of second-line chemotherapy.

METHODS

Eligible patients (pts) had metastatic or locally advanced gastro-oesophageal junction or gastric adenocarcinoma, objective tumour progression during or within 6months after first-line chemotherapy and ECOG performance status 0-2. Stratification for time of progression after first-line therapy, ECOG PS and pretreatment secured even distribution of important prognostic factors.

TREATMENT

Arm A: Irinotecan 250mg/m(2)q3w (first cycle) to be increased to 350mg/m(2), depending on toxicity. Arm B: BSC.

FINDINGS

Between 10/2002 and 12/2006 40 pts were randomised. The study was closed prematurely due to poor accrual. Responsefor arm A (19 pts evaluable): No objective responses, SD 53%, PD 47%. Improvement of tumour related symptoms: Arm A 50% of pts, arm B 7%. Overall Survival: (all events in 40 pts have occurred): The hazard ratio for death was reduced to 0.48 (95%CI 0.25-0.92) in the irinotecan-arm (p=0.012). Median survival arm A: 4.0months (95% CI 3.6-7.5), arm B: 2.4months (95% CI 1.7-4.9).

INTERPRETATION

Irinotecan as second-line chemotherapy significantly prolongs overall survival compared to BSC in the studied pts. Second-line chemotherapy can now be considered as a proven treatment option for metastatic or locally advanced gastric cancer.

FUNDING

The study was supported by a research grant from Aventis and Pfizer.

Long-term outcome of ATG vs. Basiliximab induction

BACKGROUND

An evaluation of the long-term efficacy and incidence of adverse events after induction therapy with antithymocyte globulin (ATG) vs. Basiliximab in renal transplant patients.

METHODS

Sixty recipients receiving ATG induction and a dual immunosuppression with Tacrolimus and steroids were compared retrospectively with 60 patients treated with Basiliximab. The following characteristics were evaluated: concomitant immunosuppression, recipient age, donor age, time on dialysis, cold ischemia time, year of transplantation and HLA mismatches.

RESULTS

The 6-year patient survival in the ATG group was 91·7% compared to 85% in the Basiliximab group (not significant, n.s.). Graft survival at 6 years was 89·7% and. 83·6% in the ATG and the Basiliximab group (n.s.), respectively. Incidence of biopsy proven acute rejection episodes (33·3% vs. 26·7%) and delayed graft function (30% vs. 33·3%) were similar in both groups. Kidney function was not significantly different at 1 and 6 years. CMV infections were more prevalent in the ATG arm (22% vs. 5%; P = 0·05), and a significantly higher rate of haematological complications was observed following ATG induction.

CONCLUSIONS

ATG induction was associated with an improved (but n.s.) trend in patient and graft survival. Patients induced with ATG had a higher rate of CMV infections and haematological complications.

Ion-Beam-Induced Plastic Deformation of Amorphous Materials

At temperatures far below the glass transition temperature metallic glasses undergo plastic deformation during irradiation with a beam of fast heavy ions at energies at which electronic stopping is the dominant deceleration mechanism. This plastic deformation causes irreversible anisotropic changes in sample dimensions. Various (Fe,Co,Ni)∼8O(B,Si)∼20 glasses and the crystalline alloys Ni80Cr20 and Fe70Cr25A15 are examin? 9 for their susceptibility to this effect by irradiation below 50 K with 129Xe ions at 2.8 MeV/u. The data suggest that the excess free volume of an amorphous material is an essential parameter for the magnitude of ion-beam-induced plastic deformation.

Additive growth inhibition after combined treatment of 2-methoxyestradiol and conventional chemotherapeutic agents in human pancreatic cancer cells

OBJECTIVE

Most chemotherapeutic regimens for pancreatic cancer (PC) use combination therapy. 2-Methoxyestradiol (2-ME2) is a natural estrogen metabolite with proven tumor-inhibiting effect as a single agent. The aim of this study was to determine whether a combination of 2-ME2 with other established chemotherapeutic compounds increases its tumor-inhibiting effect on human PC cells.

MATERIALS AND METHODS

The human PC cell lines AsPC-1 and MiaPaCa-2 were treated with 2-ME2 alone or in combination with different doses of gemcitabine, cisplatin, cetuximab, 5-fluorouracil and paclitaxel in vitro (range: 0.5-5 μM). FACS analysis and nuclear staining were used to reveal apoptotic cells and cell-cycle changes after treatment. Subsequent in vivo experiments were performed on a subcutaneous tumor model in nude mice using AsPC-1 cells.

RESULTS

A tumor-reductive effect of 2-ME2 was found in both human PC cell lines. The combination of 2-ME2 with other agents resulted in additive growth inhibition of both cell lines through the induction of apoptosis and cell-cycle arrest. The growth inhibition was confirmed in vivo. After 32 days' treatment, gemcitabine alone showed no effect on tumor growth at a dose of 75 mg/kg body-weight. However, 2-ME2 at a daily dose of 2 mg per animal led to a growth inhibition of 63% with no evident toxicity. The combination of 2-ME2 and gemcitabine caused a growth-inhibition of 83%. Major toxicity was observed in the combination group, with six deaths out of eight animals in this group.

CONCLUSION

2-ME2 can be successfully combined with other chemotherapeutic agents. However, toxicity in the in vivo experiment is strong and requires further investigation.

[Diagnosis and treatment of gastric cancer]

From a global perspective, gastric cancer including cancer of the esophago-gastric junction is the fourth most common malignant tumor and the second-most common cause of cancer-related death. Due to the lack of screening programs in Western countries, most gastric cancers are diagnosed in advanced stages. A sophisticated staging should include high-resolution computed tomography of the thorax, abdomen and pelvis and video-documented endoscopy and endoscopic ultrasound. In mucosal gastric cancer, endoscopic resection can replace surgical resection if specific criteria are present. In the stages II and III perioperative chemotherapy has been established as a standard of care and should be applied. In the metastatic setting, treatment goals are palliative. Chemotherapy can prolong survival, improve symptoms and can help to maintain a better quality of life. Combination chemotherapy including a platinum compound and a fluoropyrimidine regarded as standard. About 20 % of gastric cancers exhibit overexpression of the growth factor receptor family member Her2. Trastuzumab is a monoclonal antibody directed against Her2 and has shown to prolong survival when combined with cisplatin and 5-fluorouracil or capecitabine.

Initial results of MR-guided liver resection in a high-field open MRI

BACKGROUND

The goal of this study was to evaluate high-field open magnetic resonance imaging (MRI) for intraoperative real-time imaging during hand-assisted laparoscopic liver resection. MR guidance has several advantages compared to ultrasound and may represent a future technique for abdominal surgery. Various MRI-safe and -compatible instruments were developed, tested, and applied to realize minimally invasive liver surgery under MR guidance. As proof of the concept, liver resection was performed in a porcine model.

METHODS

All procedures were conducted in a 1.0-T open MRI unit. Imaging quality and surgical results were documented during three cadaveric and two live animal procedures. A nonferromagnetic hand port was used for manual access and the liver tissue was dissected using a Nd:YAG laser.

RESULTS

The intervention time ranged from 126 to 145 min, with a dissection time from 11 to 15 min. Both live animals survived the intervention with a blood loss of 250 and 170 ml and a specimen weight of 138 and 177 g. A dynamic T2W fast spin-echo sequence allowed real-time imaging (1.5 s/image) with good delineation of major and small hepatic vessels. The newly developed MR-compatible instruments and camera system caused only minor interferences and artifacts of the MR image.

CONCLUSION

MR-guided liver resection is feasible and provides additional image information to the surgeon. We conclude that MR-guided laparoscopic liver resection improves the anatomical orientation and may increase the safety of future minimally invasive liver surgery.

Systematic evaluation of the intraoperative tumor pattern in patients with borderline tumor of the ovary

OBJECTIVE

Borderline ovarian tumors (BOTs) are rare entities with excellent prognosis depending on tumor stage and presence of invasive implants. There are limited data regarding the intraoperative tumor pattern, the actual base of optimal treatment planning. We conducted a systematic evaluation of the macroscopic and microscopic tumor spreads in patients with BOTs with special focus on the diagnosis of invasive and noninvasive lesions.

METHODS

Between January 2001 and July 2008, data of patients with BOTs were evaluated using a systematic and validated documentation tool (intraoperative mapping of ovarian cancer). Surgical outcome and pathological findings were analyzed.

RESULTS

Fifty-one patients underwent surgery for BOT. Mean (SD) age was 47.76 (15.9) years. In 6 patients (11.8%), surgery was performed for recurrence. Complete tumor resection was achieved in 47 patients (92.15%), whereas mean (SD) operative time was 126.34 (73.4) minutes. Pathologic evaluation identified 12 patients (23.53%) with mucinous and 39 patients (76.47%) with serous histologic diagnoses. Twenty-nine (56.86%) and 22 patients (43.13%) were found to have unilateral and bilateral ovarian involvements, respectively. Sixteen patients (31.37%) presented extraovarian involvement into the peritoneum (23.5%), omentum (17.7%), uterus (7.84%), sigmoid (7.8%), lymph nodes (7.8%), ileum (3.9%), mesentery (5.9%), and appendix (1.96%). Twenty patients (39.2%) had implants; of those, 9 (17.64%) and 11 patients (21.6%) have invasive and noninvasive lesions, respectively. Eight of the 9 patients with positive peritoneal cytology were associated with the presence of peritoneal implants; 3 of them with invasive character.

CONCLUSIONS

Borderline ovarian tumors require a systematic surgical evaluation to verify or exclude extrapelvic tumor lesions and allow further clinical relevant differentiation between invasive and noninvasive implants.

Traumatized Liver Grafts for Organ Donation? A Single-Center Experience

Because the number of patients on waiting lists increases each year, new strategies are urgently needed to expand the donor pool. The use of traumatized donor livers for orthotopic liver transplantation at a transplant center is described. After transplantation, no increased incidence of perioperative complications such as bleeding, bile leakage, or liver graft dysfunction were observed and the transplanted livers exhibited appropriate long-term function. Thus, the use of injured livers may offer new opportunities in transplantation.

Results of liver resection in combination with radiofrequency ablation for hepatic malignancies

INTRODUCTION

Liver tumors should be surgically treated whenever possible. In the case of bilobar disease or coexisting liver cirrhosis, surgical options are limited. Radiofrequency ablation (RFA) has been successfully used for irresectable liver tumors. The combination of hepatic resection and RFA extends the feasibility of open surgical procedures in patients with liver metastases and hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

RFA was performed with two different monopolar devices using ultrasound guidance. Intraoperative use of RFA for the treatment of liver metastases or HCC was limited to otherwise irresectable tumors during open surgical procedures including hepatic resections. Irresectability was considered if bilobar disease was treated, the functional hepatic reserve was impaired or appraised marginal for allowing further resection.

RESULTS

Ten patients with both liver metastases and HCC, and two patients with cholangiocellular carcinoma were treated. Complete initial tumor clearance was achieved in all patients. Two patients of the metastases group and five patients of the HCC group suffered from local recurrence after a median of 12 months (1-26) (local recurrence rate 32%). Five patients of the metastases group and six patients of the HCC group developed recurrent tumors in different areas of the ablation site after a median time of 4 months (2-18) (distant intrahepatic recurrence in 55%). Survival at 31 months was 36%.

CONCLUSION

RFA extends the scope of surgery in some candidates with intraoperatively found irresectability.

Open surgical is superior to percutaneous access for radiofrequency ablation of hepatic metastases

PURPOSE

This study was designed to determine the best approach to radiofrequency ablation (RFA) in the liver.

METHODS

From a total of 41 procedures, 37 patients with 47 tumors were treated with RFA for metastatic disease. Indications included colorectal cancer (n=28, 68%), neuroendocrine tumors (n=2, 5%), gynecological primaries (n=4, 10%), pancreatic/duodenal cancer (n=2, 5%), and miscellaneous entities (n=5, 12%). Mean follow-up period was 18 (median, 18) months. All ways of approach to RFA were applied: percutaneous was chosen in 17 (41.5%), laparoscopic and hand-assisted laparoscopic in 5 (12.2%), and open surgical in 19 cases (46.3%), and in 10 cases, RFA was combined with hepatic resection. The average maximum tumor size was 2.3 (range, 0.8-6) cm, and the mean number of nodules treated per patient in a single session was 1.3 (range, 1-3).

RESULTS

Overall survival was 59.5% at 2 years, recurrence-free 2-year survival was 12.6%, local tumor recurrence rate was 34%, and overall recurrence was 75.6%. Local tumor recurrence and disease-free survival were significantly improved in the open surgically treated patients compared with the percutaneous treatment group (15.8% [n=3] vs. 58.8% [n=10] and 11.5 vs. 7.9 months, p<0.01 [chi2 test] and p<0.05 [log-rank test], respectively).

CONCLUSIONS

Open surgical approach is superior to percutaneous access for RFA in metastatic hepatic disease.

Evidence-based perioperative management: strategic shifts in times of fast track surgery

Changes in perioperative management is an ever evolving subject. The primary aim is to improve patient care and more recently to increase economic efficacy. Data from various randomized studies have caused a shift from traditional care concepts towards evidence based multimodal treatment strategies. They may lead to dramatic changes in perioperative patient care such as the routine use of nasogastric decompression, mechanical bowel preparation and established nutrition schemes. Further aspects of modern perioperative patient care include epidural analgesia, antibiotic prophylaxis, intraoperative fluid management and early mobilization. It has been generally accepted that these multimodal treatment concepts also known as "fast track surgery" show no differences in patient morbidity while significantly reducing patient discomfort and duration of hospitalization. However, despite the evidence-based superiority, widespread implementation has not yet occurred. The aim of this review is to highlight and discuss current changes and to show future perspectives of perioperative treatment strategies.

Surgical outcome and survival analysis of young patients with primary epithelial ovarian cancer

OBJECTIVE

The mean age of diagnosis of epithelial ovarian cancer (EOC) is in the mid-fifties. Limited data exist about the clinical outcome of patients aged below 35 years. The aim of the present study was to evaluate the cancer-related characteristics, intraoperative findings, surgical outcome and survival in this group of young women.

PATIENTS AND METHODS

Within the period between 01/1989 and 06/2008, all consecutive patients younger than 35 years with histologically proven EOC were enrolled into this study. All patients' characteristics, intraoperative and histological findings, as well as survival data were systematically analyzed using a validated prospective documentation tool for the intraoperative and postoperative data collection.

RESULTS

Thirty-one patients younger than 35 years at primary diagnosis (mean age: 28.65 years; range: 15-35) were identified among 397 patients with primary EOC (7.8%). FIGO-stage III (45.2%) was the most common tumor stage and serous-papillary (54.8%) was the most frequent histological type. A complete tumor resection was achieved in 18 patients (58.1%) with only few postoperative complications. In a mean follow-up period of 44.65 months, 9 patients (29%) died. Mean progression-free survival was 74.72 months (95% CI: 34.22-115.22), whereas mean overall survival was 148.15 months (95% CI: 91.63-204.68) and hence longer than the equivalent survival data of the total patient collective.

CONCLUSION

Primary EOC in young patients (<or=35 years old) seems to be associated with a higher overall and progression-free survival, higher platinum-sensitivity rate and a rather better clinical outcome than older patients. Further multicenter studies are warranted to evaluate the underlying reasons for these observations.

Weekly cetuximab (CET) plus oxaliplatin (OX), infusional 5-fluorouracil (5-FU) and radiation therapy (RT) as neoadjuvant treatment for esophageal squamous cell carcinoma (ESCC): A phase I study of the Arbeitsgemeinschaft Internistische Onkologie (AIO)

e15507

Background: CET, a chimeric monoclonal IgG1 antibody that targets the epidermal growth factor receptor (EGFR), has proven activity in a variety of SCC models in vitro and in vivo and has also been shown to enhance the activity of both chemo- and radiotherapy. Methods: Patients (pts) with locally advanced ESCC received CET for 2 weeks at an initial dose of 400mg/m2 (d - 15) i.v. followed by 250mg/m2(d -8) before they started a neoadjuvant dose escalation regimen. Pts received weekly CET 250mg/m2 plus RT 25 x 1.8 Gy (cumulative dose 45 Gy) d1–33. Cohort 1–3 received escalating doses of OX 45–50 mg/m2 d1,8,22,29 plus 5-FU 180–200–225 mg/m2/d; d1–5,8–12,15–19,22–26,29–33). Surgery was scheduled 4–6 weeks after RT. Toxicity was assessed according to NCI-CTC. Response was categorized according to the histopathologic score. Results: 15 pts were enrolled (2 female, 13 male; mean age 62 years, ECOG-PS 0 or 1). All pts had locally advanced SCC (uT2–4, cNx, cM0–1a) of the cervical (n=1), the upper (n=5) or the distal (n=7) esophagus. 6 pts were treated in cohort 1 and 3 pts in cohort 2 without any dose limiting toxicity (DLT). Of 6 pts treated in cohort 3, 1 pt developed grade 3 diarrhea and mucositis. All other observed toxicities were mild or moderate: anemia n=12, neutropenia n=2, thrombocytopenia n=3, nausea/vomiting n=8, mucositis n=6, diarrhea n=4, neuropathy n=4, hand-foot-syndrome n=8, skin rash n=14, no infection and no infusion-related reactions were observed. 12 pts underwent abdomino-thoracic esophagectomy with no postop. mortality; 3 pts were not resected. 8/12 resected pts had an R0 resection (67%) and 4 pts (33%) achieved a histopathological complete response (score 1a). Conclusions: 2 weeks of CET (400mg/m2 and 250mg/m2) followed by weekly CET (250mg/m2) plus OX 50mg/m2 d1,8,22,29, 5-FU 225 mg/m2/d d1–5,8–12,15–19,22–26,29–33 and RT 45 Gy (1.8Gy/f) was shown to be safe as neoadjuvant treatment for locally advanced ESCC. The anti-tumor activity of this regimen is promising and is being further investigated in an ongoing phase II study.

[Table: see text]

Irinotecan versus best supportive care (BSC) as second-line therapy in gastric cancer: A randomized phase III study of the Arbeitsgemeinschaft Internistische Onkologie (AIO)

4540

Background: Up to now the value of 2nd-line therapy for metastatic gastric cancer is unclear. So far there are no randomized phase III data comparing 2nd-line chemotherapy to BSC. Irinotecan has proven activity in 1st-line therapy. In this randomized phase III study we compared irinotecan to BSC to evaluate the value of 2nd- line chemotherapy for gastric cancer. Methods: Prospective multicenter randomized phase III study, open label. Eligibility: Metastatic or locally advanced gastro-esophageal junction or gastric adenocarcinoma. Objective tumor progession (PD) within 6 months after 1st- line chemotherapy. ECOG PS 0–2. Statistics: Primary endpoint: Overall survival (OS). Hypothesis: H1: OS(Irinotecan)>OS(BSC). Calculated number of pts needed (power 80%, alpha error 5%): 60 pts per arm. Stratification for a) PD less versus (vs) more than 3 months after 1st line chemotherapy, b) ECOG PS 0/1 vs 2. Treatment: Arm A: Irinotecan 250mg/m2 q3w (1st cycle) to be increased to 350 mg/m2, depending on toxicity. Arm B: BSC Results: Between Oct 2002 and Dec 2006 40 pts were randomized. The study was closed prematurely due to poor accrual. Arm A:21 pts, arm B 19 pts. Median age A: 58 yrs (43–73), B: 55 yrs (35–72); PD less vs more than 3 months after 1st-line chemotherapy: A: 18 / 3, B: 17 / 2pts. ECOG PS 0/1 vs 2: A: 17/ 4, B: 14/ 5pts. Pre-treatment with cisplatin: A: 21, B:19 pts. Arm A: 68 cycles administered in 21 pts. Toxicity: (main CTC grade 3/ 4): Nausea 1 pt, vomiting 1 pt, diarrhoea: 5 pts, neutropenic fever: 2 pts, data incomplete 6 pts. In 37% of 19 evaluable pts irinotecan dose was escalated to 350mg/m2. Response (19 pts evaluable): No objective responses, SD 58%, PD 42%. Improvement of tumor related symptoms: 44% of pts in arm A, 5% in arm B. Survival: (evaluable pts arm A 21, arm B 18): median survival arm A: 123 days (95%CI 95–216), arm B 72.5 days (95%CI 41–106); OS: HR=2.85 (95%CI 1.41–5.79), Logrank test (two-sided): p=0.0027. Conclusions: To our knowledge this is the first randomized phase III study investigating 2nd- line chemotherapy in gastric cancer. Irinotecan as 2nd-line chemotherapy significantly prolongs overall survival compared to BSC. 2nd-line chemotherapy can now be considered as a proven option in gastric cancer.

[Table: see text]

Swift heavy ion irradiation of Cu-Zn-Al and Cu-Al-Ni alloys

The effects produced by swift heavy ions in the martensitic (18R) and austenitic phase (β) of Cu based shape memory alloys were characterized. Single crystal samples with a surface normal close to [210](18R) and [001](β) were irradiated with 200 MeV of Kr(15+), 230 MeV of Xe(15+), 350 and 600 MeV of Au(26+) and Au(29+). Changes in the microstructure were studied with transmission electron microscopy (TEM) and high resolution transmission electron microscopy (HRTEM). It was found that swift heavy ion irradiation induced nanometer sized defects in the 18R martensitic phase. In contrast, a hexagonal close-packed phase formed on the irradiated surface of β phase samples. HRTEM images of the nanometer sized defects observed in the 18R martensitic phase were compared with computer simulated images in order to interpret the origin of the observed contrast. The best agreement was obtained when the defects were assumed to consist of local composition modulations.