2-Step-Scores with optional nephropathology for the prediction of adverse outcomes for brain-dead donor kidneys in Eurotransplant

BACKGROUND AND HYPOTHESIS

The decision for acceptance or discard of the increasingly rare and marginal brain-dead donor kidneys in Eurotransplant (ET) countries has to be made without solid evidence. Thus, we developed and validated flexible clinicopathological scores called 2-Step Scores for the prognosis of delayed graft function (DGF) and one-year death-censored transplant loss (1y-tl) reflecting the current practice of six ET countries including Croatia and Belgium.

METHODS

The training set was n=620 for DGF and n=711 for 1y-tl, with validation sets n=158 and n=162. In step 1, stepwise logistic regression models including only clinical predictors were used to estimate the risks. In step 2, risk estimates were updated for statistically relevant intermediate risk percentiles with nephropathology.

RESULTS

Step 1 revealed an increased risk of DGF with increased cold ischaemia time, donor and recipient BMI, dialysis vintage, number of HLA-DR mismatches or recipient CMV IgG positivity. On the training and validation set, c-statistics were 0.672 and 0.704, respectively. At a range between 18% and 36%, accuracy of DGF-prognostication improved with nephropathology including number of glomeruli and Banff cv (updated overall c statistics of 0.696 and 0.701, respectively).Risk of 1y-tl increased in recipients with cold ischaemia time, sum of HLA-A. -B, -DR mismatches and donor age. On training and validation sets, c-statistics were 0.700 and 0.769, respectively. Accuracy of 1y-tl prediction improved (c-statistics = 0.706 and 0.765) with Banff ct. Overall, calibration was good on the training, but moderate on the validation set; discrimination was at least as good as established scores when applied to the validation set.

CONCLUSION

Our flexible 2-Step Scores with optional inclusion of time-consuming and often unavailable nephropathology should yield good results for clinical practice in ET, and may be superior to established scores. Our scores are adaptable to donation after cardiac death and perfusion pump use.

Peritoneal carcinomatosis: cytoreductive surgery and HIPEC--overview and basics

Tumor involvement of the peritoneum-peritoneal carcinomatosis-is a heterogeneous form of cancer that had been generally regarded as a sign of systemic tumor disease and as a terminal condition. The multimodal treatment approach for patients with peritoneal carcinomatosis, which had been conceived and developed, consists of what is known as cytoreductive surgery, followed by hyperthermic intraperitoneal chemotherapy (HIPEC). Depending on the tumor mass as assessed intraoperatively and the histopathological differentiation, patients who undergo cytoreductive surgery and HIPEC have a significant survival benefit. Mean increases in the survival period ranging from six months to up to four years have now been reported. In view of the substantial logistic effort and the extent of the surgery involved, this treatment approach represents a major challenge both for patients and for surgical oncologists, as well as for the members of the overall interdisciplinary structure required, which includes oncology, anesthesiology and intensive care, psycho-oncology, and patient management. The surgical procedures alone may take 8-14 hr. The present paper provides an overview of the basis for the approach and the use of specialized classifications and quantitative prognostic indicators.

Immunomonitoring results of a phase II/III study of malignant ascites patients treated with the trifunctional antibody catumaxomab (anti-EpCAM x anti-CD3)

Patients with malignant ascites secondary to primary carcinomas benefit from intraperitoneal therapy with the trifunctional antibody catumaxomab (anti-EpCAM × anti-CD3). Here, we report the analysis of peritoneal fluid samples from 258 patients with malignant ascites randomized to catumaxomab or control groups to investigate the molecular effects of catumaxomab treatment. In the catumaxomab group, tumor cell numbers and peritoneal levels of VEGF decreased, whereas the activation status of CD4(+) and CD8(+) T-cell populations increased more than two-fold after treatment. Notably, CD133(+)/EpCAM(+) cancer stem cells vanished from the catumaxomab samples but not from the control samples. In vitro investigations indicated that catumaxomab eliminated tumor cells in a manner associated with release of proinflammatory Th1 cytokines. Together, our findings show that catumaxomab therapy activates peritoneal T cells and eliminates EpCAM(+) tumor cells, establishing a molecular and cellular basis to understand in vivo efficacy within the immunosuppressed malignant ascites tissue microenvironment.

Peritoneal carcinomatosis immunotherapy with the trifunctional anti-EpCAM x anti-CD3 antibody catumaxomab in patients with colon, gastric, or pancreatic cancer: Long-term results after a 2-year follow-up

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Background: Peritoneal carcinomatosis (PC) from gastrointestinal (GI) cancer is associated with a poor outcome. The trifunctional antibody catumaxomab may induce remission by redirecting T-lymphocytes and Fcγ-receptor I/III positive accessory cells to tumor cells. The aim of this study was to investigate the treatment of PC with intraperitoneal catumaxomab. Methods: Patients with epithelial cell adhesion molecule (EpCAM)-positive PC from GI cancer were enrolled in a multicenter phase I study and received four sequential intraperitoneal catumaxomab infusions on days 0, 3, 7, and 10 at increasing doses. Results: Twenty-four patients were enrolled. The maximum tolerated dose (MTD) was reached at 10, 20, 50, and 200 μg on days 0, 3, 7, and 10, respectively. The most common drug-related adverse events at the MTD were fever, vomiting, abdominal pain, skin toxicity, and nausea. Eleven of 17 evaluable patients (65%) were progression-free at final examination: one patient had a complete response and three patients had a partial response. EpCAM-positive cells in peritoneal lavage samples decreased in six of 10 evaluable patients. Patient survival was compared in a post hoc matched-pair analysis with PC patients treated with conventional intravenous chemotherapy. Median survival from the time of diagnosis of PC was 502 days in study patients versus 180 days in control patients (log-rank p = .0083). Conclusions: Intraperitoneal treatment with catumaxomab had an acceptable safety profile. Elimination of tumor cells from peritoneal lavage samples, delayed disease progression, and prolonged survival indicate that intraperitoneal catumaxomab is a promising option for the treatment of PC from GI cancer.

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