Risk of Myelopathy Following Second Local Treatment after Initial Irradiation of Spine Metastasis

Metastatic lesions of the spine occur in up to 40% of cancer patients and are a frequent source of pain and neurologic deficit due to cord compression. Palliative radiotherapy is the main first-intent local treatment in the form of single-fraction radiotherapy or fractionated courses. Reirradiation is a viable option for inoperable patients where spinal decompression is needed but with an increased risk of radiation-induced myelopathy (RM) and subsequent neurologic damage. This review summarizes reported data on local treatment options after initial irradiation in patients with relapsed spine metastasis and key dosimetric correlations between the risk of spinal cord injury and reirradiation technique, total dose, and time between treatments. The Linear Quadratic (LQ) model was used to convert all the published doses into biologically effective doses and normalize them to EQD2. For 3D radiotherapy, authors used cumulative doses from 55.2 Gy2/2 to 65.5 Gy2/2 EQD2 with no cases of RM mentioned. We found little evidence of RM after SBRT in the papers that met our criteria of inclusion, usually at the median reported dose to critical neural tissue around 93.5 Gy2/2. There is a lack of consistency in reporting the spinal cord dose, which leads to difficulty in pooling data.

Antidiabetics, Anthelmintics, Statins, and Beta-Blockers as Co-Adjuvant Drugs in Cancer Therapy

Over the last years, repurposed agents have provided growing evidence of fast implementation in oncology treatment such as certain antimalarial, anthelmintic, antibiotics, anti-inflammatory, antihypertensive, antihyperlipidemic, antidiabetic agents. In this study, the four agents of choice were present in our patients’ daily treatment for nonmalignant-associated pathology and have known, light toxicity profiles. It is quite common for a given patient’s daily administration schedule to include two or three of these drugs for the duration of their treatment. We chose to review the latest literature concerning metformin, employed as a first-line treatment for type 2 diabetes; mebendazole, as an anthelmintic; atorvastatin, as a cholesterol-lowering drug; propranolol, used in cardiovascular diseases as a nonspecific inhibitor of beta-1 and beta-2 adrenergic receptors. At the same time, certain key action mechanisms make them feasible antitumor agents such as for mitochondrial ETC inhibition, activation of the enzyme adenosine monophosphate-activated protein kinase, amelioration of endogenous hyperinsulinemia, inhibition of selective tyrosine kinases (i.e., VEGFR2, TNIK, and BRAF), and mevalonate pathway inhibition. Despite the abundance of results from in vitro and in vivo studies, the only solid data from randomized clinical trials confirm metformin-related oncological benefits for only a small subset of nondiabetic patients with HER2-positive breast cancer and early-stage colorectal cancer. At the same time, clinical studies confirm metformin-related detrimental/lack of an effect for lung, breast, prostate cancer, and glioblastoma. For atorvastatin we see a clinical oncological benefit in patients and head and neck cancer, with a trend towards radioprotection of critical structures, thus supporting the role of atorvastatin as a promising agent for concomitant association with radiotherapy. Propranolol-related increased outcomes were seen in clinical studies in patients with melanoma, breast cancer, and sarcoma.

Impact of the COVID-19 Pandemic on Treatment and Oncologic Outcomes for Cancer Patients in Romania

BACKGROUND/AIM

This study aimed to assess the impact of the ongoing COVID-19 pandemic on cancer patients, known to be immune-compromised due to the disease itself, oncological treatments and adjuvant medicines use such as steroids. Overall survival was determined for patients with COVID-19 infection and stratification according to known comorbidities and complications was performed.

PATIENTS AND METHODS

This prospective study included ninety cancer patients with COVID-19 confirmed by PCR testing performed before each cycle of chemotherapy or every two weeks during radiotherapy between May and December 2020 in two tertiary Cancer Centers. Demographic, cancer-related and SARS-CoV-2 infection data were collected and long-term oncologic outcome was assessed.

RESULTS

Mean age of cancer patients diagnosed with SARS-CoV-2 was 59.7±12.1 years (range=30-83 years). Fifty-two (57.7%) were women. The most frequent cancer localization was breast (n=28, 31.1%) followed by colorectal (n=11, 12.2%) and lung cancer (n=8, 8.8%). Most patients infected with SARS-CoV-2 were diagnosed in stage IV of the disease (n=44, 48.9%) followed by stage III (n=19, 21.1%) and stage II disease (18.9%). Regarding comorbidities, the most common was hypertension (n=31) followed by cardiac dysfunction (n=23) and type II diabetes (n=13). Of 27 (30%) patients who needed hospitalization, 4 patients developed severe infection, 17 patients had mild symptoms and 6 patients were minimally symptomatic. After a median follow-up of 22.5 months, 5 patients (5.55%) died due to SARS-COV-2 infection, all stages III and IV. Median estimated overall survival was 14 months in patients who died because of COVID infection compared to 98 months in cancer-related mortality analysis (p<0.0001). Three deaths occurred during chemotherapy, 1 death in the chemoradiotherapy radiotherapy group.

CONCLUSION

SARS-CoV-2 infection was associated with an excess mortality in our study population, especially in patients with advanced and metastatic disease and in those receiving immunosuppressive treatment such as chemotherapy and radiotherapy.

The Role of Programmed Cell Death Receptor 1 in Lung Cancer

BACKGROUND/AIM

Lung cancer is the most common cancer worldwide. Cancer immunotherapy is the activation of the immune system against cancer. The latest method of immunotherapy involves immune checkpoint inhibitors. Increased levels of programmed death ligand 1 (PD-L1) expression were observed on non-small-cell lung cancer. The association between PD-L1 expression and clinicopathological characteristics in lung cancer is still unclear.

PATIENTS AND METHODS

This is a cross-sectional, observational study that evaluated a sample of 41 lung cancer patients diagnosed between March 2019 and December 2020. PD-L1 tumor expression is described as a percentage.

RESULTS

Patients were diagnosed with non-microcellular lung cancer and aged 37 to 87 years. Most patients were diagnosed with adenocarcinoma. According to the analysis, the average age of patients with negative PD-L1 tumors was 65.6 years, and of those with positive PD-L1 tumors was 63.6 years. The average value of the tumor proportion score for males was 26.97%, and for females 25.55%.

CONCLUSION

No correlation was found between PD-L1 tumor expression and the age and sex of patients.

Management of Epicardial Metastasis in Breast Cancer

Background: Cardiac metastasis may be encountered more frequently than primary cardiac tumors. They are discovered at autopsies with an incidence between 1.5 - 20%. The primary tumors that generate cardiac metastasis are malignant melanomas, lymphoma, the lungs, the breast, the esophagus. The organ most affected is the pericardium (62-81%). In 90% of cases from a clinical point of view, they are generally silent. In the case of patients diagnosed with breast cancer and who have undergone radiotherapy, differential diagnosis with fibrosis post radiotherapy interferes. The treatment is palliative and should be administered according to the primary location of the tumor and the patient's performance status. Case presentation: We are presenting the case of a 73-year-old diagnosed and treated for a breast neoplasm in the left breast in 2006. After a period of time of 9 years, the patient presents secondary sternal bone determination, radio-treated and for which she once again goes under hormonal therapy. In 2018, patient performed an imaging evaluation that revealed lung metastases. At the moment of stage review, performed in 2020, secondary epicardial determinations are noted. We present the case, the therapeutic management, diagnostic procedures and treatment and also, we discuss the data from literature. Conclusion: Cardiac metastases are rare and and in most cases are silent. The incidence has changed due to treatment options and imaging investigations. Stereotactic body radiation therapy can be considereda a therapeutic option in the cases with good performance status and with oligometastatic disease.

Modulation of Immune System - Strategy in the Treatment of Breast Cancer

BACKGROUND/AIM

In women, breast cancer is the most commonly diagnosed cancer type and at the same time the main cause of cancer-related death. Many mechanisms are involved in the tumor microenvironment to restrict the anti-tumor activity by the immune system. Identification of novel prognostic tools based on immunological data could make significant impact in developing innovative immunotherapy strategies that will restore the anti-tumor immune system efficacy.

PATIENTS AND METHODS

The study was performed on patients diagnosed with breast cancer, who were divided into two groups depending on the expression of HER2. For the studied group, first we described the infiltrate inflammatory on slides stained with haematoxylin eosin (HE) and in the second part we used flow cytometry in order to measure the percentage of T lymphocytes from the peripheral blood before and after breast cancer treatment.

RESULTS

High presence of tumor-infiltrating lymphocytes (TILs) was associated with prognostic improvement, better disease-free survival, distant disease-free survival and overall survival. In breast cancer, the presence of TILs predicts the full pathological response rate (pCR) after neoadjuvant chemotherapy. TILs are one of the best examples of the strict relationship existing between natural defence and carcinogenesis.

CONCLUSION

Modulation of the immune system is a promising strategy in the treatment of breast cancer, especially in triple-negative and HER2-positive molecular subtypes, the most immunogenic subtypes with a poor prognosis.

Management of Diagnosis and Treatment in a Case of Fibrolamellar Carcinoma

BACKGROUND/AIM

Fibrolamellar carcinoma is a rare primary hepatic malignancy that has recently been recognized as a distinct clinical entity, highly different from the well-known hepatocellular carcinoma. This report describes the clinical and paraclinical aspects of the fibrolamellar carcinoma, emphasizing its particularities.

CASE REPORT

A 30-year-old patient presented to the hospital with nonspecific symptoms and weight loss, with imaging findings showing abdominal and mediastinal masses. Multiple biopsies were performed, leading to a diagnosis of metastatic fibrolamellar carcinoma. Given the extent of the disease, systemic drug treatment was administered, although prognosis was poor with tumor growth, resulting in biliary duct invasion.

CONCLUSION

Fibrolamellar carcinoma is a rare type of malignancy, with a difficult differential diagnosis in which imaging techniques are important but for which biopsy remains the gold standard. The prognosis depends on tumor extent and may include surgical methods or chemotherapy.

Biomolecular Factors Represented by Bcl-2, p53, and Tumor-Infiltrating Lymphocytes Predict Response for Adjuvant Anthracycline Chemotherapy in Patients with Early Triple-Negative Breast Cancer

Treatment of triple-negative breast cancer is challenging. Standard adjuvant tretment is considered to be the cobination of anthracycline and taxanes although the role of anthracyclines administered preoperatively  remains controversial. Actually, some studies recommended taxane-only regimens. We reviewed literatures to examine whether tissue biomarkers available in an ordinary laboratory setting (eg, haematoxylin and eosin and immunohistochemistry) may predict response to adjuvant anthracyclines in patients with triple-negative breast cancer. Our review showed that Bcl-2, p53, and tumor-infiltrating lymphocytes (TILs) expression may become independent predictors for triple-negative breast cancer. This finding was based on data from retrospective studies, and, thus, randomized controlled study is needed to confirm the present results.

RADT-30. COPLANAR AND NON-COPLANAR VMAT ARC SETTING FOR GLIOBLASTOMA MULTIFORME – DOSIMETRIC AND RADIOBIOLOGICAL COMPARISONS

OBJECTIVES

To evaluate three different arc arrangements in glioblastoma multiforme (GBM) treatment planning.

METHODS

Eighteen GBM patients were replanned by using one full arc (1FA), two full coplanar arcs (2FA), and three full non- coplanar arcs (3FA). Dose-volume histograms (DVHs) were used to calculate conformity (CI), homogeneity (HI) and gradient indices (GI), the dose received by 5% (D5%) and 95% (D95%) of the planning target volume (PTV) and maximum (Dmax) and minimum (Dmin) absorbed dose for organs at risk (OARs), including normal brain (brain excluding PTV). General equivalent uniform dose (gEUD) for both PTV and OARs and EUD based tumor control probability (TCP) and normal tissue control probability (NTCP) were calculated as radiobiological parameters. Monitor units (MUs) were also computed and compared.

RESULTS

All three plans resulted in similar conformity, while 2FA resulted in a better homogeneity than 1FA (0.06vs. 0.07, p=0.007). 2FA vs. 1FA dose analysis for PTV revealed a lower D5% (61.28 vs. 61.37 Gy, p=0.014), a higher D95% (58.7 vs. 58.47 Gy, p=0.008) and a higher TCP (37.73 vs.37.38%, p=0.008). The utilization of 3FA did not significantly change the outcome of PTV but managed to decrease GI in comparison to both 1FA and 2FA (4.11 vs. 5.19 and 5.49, p&lt; 0.05). Regarding NB, 1FA scored a higher Dmax than 2FA (62.32 vs. 61.98 Gy, p=0.005), while 3FA scored a higher Dmin than 1FA and 2FA (2.52 vs. 1.08 and 1.10 Gy, p&lt; 0.05). No difference in NB NTCP was noted between techniques. Furthermore, 3FA yielded more MUs when compared to coplanar patters (566.74 vs. 486.78, p= 0.015 for 1FA and 495.98, p=0.019 for 2FA).

CONCLUSION

Although all three approaches resulted in clinical admissible outcome, the utilization of complex non-coplanar arrangement resulted in a stepper dose fall off but did not improve PTV results and increased machine MUs.

Evaluation of Biochemical Markers Correlated with Breast Cancer Young Patients

Breast cancer ranks first in women in terms incidence and mortality in the world. In Romania its frequency continues to increase and now is the most common cancer in the women. Despite therapeutic advances, there is still severe cancer with heavy sequelae both physical and mental. It`s even harder to accept or even reject when it comes to a young women. For a long time, breast cancer was linked to a more or less old age. However, in the recent literature, breast cancer is on the rise more observed in a young population, its frequency is estimated at 7% all cases of breast cancer. Breast cancer diagnosed in young patients tends to be more aggressive than the rest of the cases. In this paper, we present the results of a study that included 59 women presenting primary invasive breast carcinomas selected from the database of the Institute of Oncology Bucharest in which clinical follow-up data cover long intervals of time (2014 - 2019) and whose histological pieces met technical conditions optimal for extended immunohistochemical processing. The available material resources allowed the completion of a complete analyzes in all cases in relation to the immunohistochemical examination . The correlation between the expression of each of the antibodies was calculated using Pearson correlation coefficient.

Immune Effects of Transtuzumab in HER2 Positive Breast Cancer

The immune system could mediate the antitumor activity of several anticancer treatments. Several chemotherapy compounds, including anthracyclines and oxaliplatin, induce immunogenic cell death that in turn activates the antitumor immune response. Trastuzumab induces antibody-dependant cell-mediated cytotoxicity. On the basis of this background, immune markers have recently been the focus of intense translational research to predict and monitor the efficacy of treatments. Gene expression arrays and immunohistochemistry have assessed immune activation and infiltration by macrophages, natural killer, and T and B lymphocytes. In this paper we present the results of a study that included 22 patients diagnosed with Her2 positive breast cancer undergoing treatment with Transtuzumab.

Malondialdehyde as a Prognostic Marker in Patients with Ovarian Adenocarcinoma

Oxidative stress is defined as the imbalance between reactive oxygen species and cellular antioxidative mechanisms. Reactive oxygen species are involved in the development and progression of many cancers and has been showed to activate pro-tumorigenic signalling, increase tumour cell survival, proliferation, invasion and metastasis, DNA damage and genetic instability. These are highly reactive and attack various classes of essentials biomolecules such as proteins, DNA and most important lipids. Malondialdehyde is the best investigated product of lipid peroxidation. The aim of this study was to evaluate the prognostic role of malondialdehyde in patients with ovarian adenocarcinoma and in an experimental model.

NBTXR3, a first-in-class radioenhancer hafnium oxide nanoparticle, plus radiotherapy versus radiotherapy alone in patients with locally advanced soft-tissue sarcoma (Act.In.Sarc): a multicentre, phase 2-3, randomised, controlled trial

BACKGROUND

Pathological complete response to preoperative treatment in adults with soft-tissue sarcoma can be achieved in only a few patients receiving radiotherapy. This phase 2-3 trial evaluated the safety and efficacy of the hafnium oxide (HfO₂) nanoparticle NBTXR3 activated by radiotherapy versus radiotherapy alone as a pre-operative treatment in patients with locally advanced soft-tissue sarcoma.

METHODS

Act.In.Sarc is a phase 2-3 randomised, multicentre, international trial. Adults (aged ≥18 years) with locally advanced soft-tissue sarcoma of the extremity or trunk wall, of any histological grade, and requiring preoperative radiotherapy were included. Patients had to have a WHO performance status of 0-2 and a life expectancy of at least 6 months. Patients were randomly assigned (1:1) by an interactive web response system to receive either NBTXR3 (volume corresponding to 10% of baseline tumour volume at a fixed concentration of 53·3 g/L) as a single intratumoural administration before preoperative external-beam radiotherapy (50 Gy in 25 fractions) or radiotherapy alone, followed by surgery. Randomisation was stratified by histological subtype (myxoid liposarcoma vs others). This was an open-label study. The primary endpoint was the proportion of patients with a pathological complete response, assessed by a central pathology review board following European Organisation for Research and Treatment of Cancer guidelines in the intention-to-treat population full analysis set. Safety analyses were done in all patients who received at least one puncture and injection of NBTXR3 or at least one dose of radiotherapy. This study is registered with ClinicalTrials.gov, number NCT02379845, and is ongoing for long-term follow-up, but recruitment is complete.

FINDINGS

Between March 3, 2015, and Nov 21, 2017, 180 eligible patients were enrolled and randomly assigned and 179 started treatment: 89 in the NBTXR3 plus radiotherapy group and 90 in the radiotherapy alone group. Two patients in the NBTXR3 group and one patient in the radiotherapy group were excluded from the efficacy analysis because they were subsequently discovered to be ineligible; thus, a total of 176 patients were analysed for the primary endpoint in the intention-to-treat full analysis set (87 in the NBTXR3 group and 89 in the radiotherapy alone group). A pathological complete response was noted in 14 (16%) of 87 patients in the NBTXR3 group and seven (8%) of 89 in the radiotherapy alone group (p=0·044). In both treatment groups, the most common grade 3-4 treatment-emergent adverse event was postoperative wound complication (eight [9%] of 89 patients in the NBTXR3 group and eight [9%] of 90 in the radiotherapy alone group). The most common grade 3-4 adverse events related to NBTXR3 administration were injection site pain (four [4%] of 89) and hypotension (four [4%]) and the most common grade 3-4 radiotherapy-related adverse event was radiation skin injury in both groups (five [6%] of 89 in the NBTXR3 group and four [4%] of 90 in the radiotherapy alone group). The most common treatment-emergent grade 3-4 adverse event related to NBTXR3 was hypotension (six [7%] of 89 patients). Serious adverse events were observed in 35 (39%) of 89 patients in the NBTXR3 group and 27 (30%) of 90 patients in the radiotherapy alone group. No treatment-related deaths occurred.

INTERPRETATION

This trial validates the mode of action of this new class of radioenhancer, which potentially opens a large field of clinical applications in soft-tissue sarcoma and possibly other cancers.

FUNDING

Nanobiotix SA.

Variation of the T Lymphocytes According to Treatment in Breast Cancer

Breast cancer is a multifaceted disease whose varied phenotype recapitulates only partially the biological complexity. At present, there are new approaches to the diagnosis and treatment of this form of cancer, but research should also focus on identifying and implementing other individual prognostic factors, factors that may lead to improved clinical decision making with regard to the patient, in order to establish an individualized treatment.

Tumor is an Oxidative Stress Factor in Ovarian Cancer Patients

Introduction: Epithelial ovarian cancer is worldwide the second cause of gynaecological cancer but the commonest cause of gynaecological cancer-associated death.

AIM

To determine the intensity of oxidative stress in ovarian cancer patients and to establish a connection between the presence of the tumor and reactive oxygen species (ROS).

PATIENTS AND METHODS

Thirty-five patients diagnosed with epithelial ovarian carcinoma stage II-IV between 2010 and 2017, who underwent multimodality treatment (surgery and chemotherapy) were included in the study. ROS measured in dynamic (four determinations between every cycle) were malondialdehyde to evaluate the lipid peroxidation, ceruloplasmin, SH- albumin thiols groups and total antioxidants. Results: There was an increase in the value of ROS: malondialdehyde mean value was 8.1 µmol/100 ml (normal value 4 µmol/100 ml); ceruloplasmin mean value was 144.8U.I. (normal value 120U.I), both showing an active oxidative process in patients with ovarian cancer. A small decrease of the value of thiols (395 vs. 450 µmol/l) and a small increase of total antioxidants was noticed (1.44 vs. 1.4 µmol). All four compounds decrease between the first determination and the fourth one. There was a strong correlation between lipid peroxides levels and ceruloplasmin (Pearson correlation 0.315 p=0.005) and between lipid peroxides and thiols groups (Pearson correlation 0.23 p=0.039). There was a correlation between thiols and antioxidants (Pearson correlation 0.33 p=0.003). Lipid peroxidation and ceruloplasmin were significantly higher in patients with residual disease (p=0.039, p=0.046) emphasizing that the tumor is a generator of oxidative stress.

CONCLUSION

Tumor produces ROS in excess in patients with advanced ovarian adenocarcinoma. Those ROS are corelated and acts as signalling molecules.

A Randomized Phase II Trial (TAMIGA) Evaluating the Efficacy and Safety of Continuous Bevacizumab Through Multiple Lines of Treatment for Recurrent Glioblastoma

BACKGROUND

We assessed the efficacy and safety of bevacizumab (BEV) through multiple lines in patients with recurrent glioblastoma who had progressed after first-line treatment with radiotherapy, temozolomide, and BEV.

PATIENTS AND METHODS

TAMIGA (NCT01860638) was a phase II, randomized, double-blind, placebo-controlled, multicenter trial in adult patients with glioblastoma. Following surgery, patients with newly diagnosed glioblastoma received first-line treatment consisting of radiotherapy plus temozolomide and BEV, followed by six cycles of temozolomide and BEV, then BEV monotherapy until disease progression (PD1). Randomization occurred at PD1 (second line), and patients received lomustine (CCNU) plus BEV (CCNU + BEV) or CCNU plus placebo (CCNU + placebo) until further disease progression (PD2). At PD2 (third line), patients continued BEV or placebo with chemotherapy (investigator's choice). The primary endpoint was survival from randomization. Secondary endpoints were progression-free survival in the second and third lines (PFS2 and PFS3) and safety.

RESULTS

Of the 296 patients enrolled, 123 were randomized at PD1 (CCNU + BEV, n = 61; CCNU + placebo, n = 62). The study was terminated prematurely because of the high drop-out rate during first-line treatment, implying underpowered inferential testing. The proportion of patients receiving corticosteroids at randomization was similar (BEV 33%, placebo 31%). For the CCNU + BEV and CCNU + placebo groups, respectively, median survival from randomization was 6.4 versus 5.5 months (stratified hazard ratio [HR], 1.04; 95% confidence interval [CI], 0.69-1.59), median PFS2 was 2.3 versus 1.8 months (stratified HR, 0.70; 95% CI, 0.48-1.00), median PFS3 was 2.0 versus 2.2 months (stratified HR, 0.70; 95% CI, 0.37-1.33), and median time from randomization to a deterioration in health-related quality of life was 1.4 versus 1.3 months (stratified HR, 0.76; 95% CI, 0.52-1.12). The incidence of treatment-related grade 3 to 4 adverse events was 19% (CCNU + BEV) versus 15% (CCNU + placebo).

CONCLUSION

There was no survival benefit and no detriment observed with continuing BEV through multiple lines in patients with recurrent glioblastoma.

IMPLICATIONS FOR PRACTICE

Previous research suggested that there may be value in continuing bevacizumab (BEV) beyond progression through multiple lines of therapy. No survival benefit was observed with the use of BEV through multiple lines in patients with glioblastoma who had progressed after first-line treatment (radiotherapy + temozolomide + BEV). No new safety concerns arose from the use of BEV through multiple lines of therapy.

Distant Oncologic Outcome of Patients with Locally Advanced Unresectable and Metastatic Esophageal Cancer after Multimodality Treatment

Background: Combined modality therapy has been employed for the treatment of choice for locally advanced esophageal and eso-gastric junction cancers all around the globe but a unanimous consensus is missing. Methods: Medical files of 132 patients with confirmed locally advanced un-resectable, and metastatic esophageal cancer who presented to our center between 2010-2015 were retrospectively reviewed. Multimodality treatment consisting of chemo-radiotherapy or chemotherapy or radiotherapy alone and surgery in patients who convert to operability was planned according to tumor extend and performance status of the patient. Results: Seventy seven percent of the patient presented with squamous carcinoma and 23 % were adenocarcinoma. At the diagnosis 22 patients (16.6%) were stage IV. Concurrent chemoradiotherapy was administered in 26 patients (19.7%), chemotherapy in 91 patients (68.9%), radiotherapy in 83 patients (62.9%). After combined treatment, surgery with radical intent was possible in 21 patients (15.9%). After a follow up of 17.3 months, overall survival (OS) was 12 months, with one and two-year survival rate of 49.2% and 17.4%. In metastatic patients OS was 10 months. Patients who were converted to operability had a OS of 20 months vs. 10 months in patients who doesn't undergo surgery (p=0.002). Chemo-radiotherapy was superior in terms of OS compare with chemotherapy or radiotherapy administered sequential (17 vs. 10 months, p=0.013). Conclusions: Multimodality treatment in locally advanced esophageal cancers (concurrent radiochemotherapy followed by surgery) can be considered superior to each method as single therapy and radiotherapy and chemotherapy can make certain locally advanced esophageal tumors resectable.

Variation in uterus position prior to brachytherapy of the cervix: A case report

Rationale: brachytherapy is administered in the treatment of patients with locally advanced cervical cancer following chemoradiotherapy. Lack of local anatomy evaluation prior to this procedure might lead to the selection of an inappropriate brachytherapy applicator, increasing the risk of side effects (e.g. uterus perforation, painful procedure ...). Objective: To assess the movement of the uterus and cervix prior to brachytherapy in patients with gynecological cancer, in order to select the proper type of brachytherapy applicator. Also we wanted to promote the replacement of the plain X-ray brachytherapy with the image-guided procedure. Methods and results: We presented the case of a 41-year-old female diagnosed with a biopsy that was proven cervical cancer stage IIIB. At diagnosis, the imaging studies identified an anteverted uterus. The patient underwent preoperative chemoradiotherapy. Prior to brachytherapy, the patient underwent a pelvic magnetic resonance imaging (MRI), which identified a displacement of the uterus in the retroverted position. Discussion: A great variety of brachytherapy applicators is available nowadays. Major changes in uterus position and lack of evaluation prior to brachytherapy might lead to a higher rate of incidents during this procedure. Also, by using orthogonal simulation and bidimensional (2D) treatment planning, brachytherapy would undoubtedly fail to treat the remaining tumoral tissue. This is the reason why we proposed the implementation of a prior imaging of the uterus and computed tomography (CT)/ MRI-based simulation in the brachytherapy procedure. Abbreviations: MRI = magnetic resonance imaging, CT = computed tomography, CTV = clinical target volume, DVH = dose-volume histogram, EBRT = external beam radiotherapy, GTV = gross tumor volume, Gy = Gray (unit), ICRU = International Commission of Radiation Units, IGRT = image guided radiotherapy, IM = internal margin, IMRT = image modulated radiotherapy, ITV = internal target volume, MRI = magnetic resonance imaging, OAR = organs at risk, PTV = planning target volume, QUANTEC = Quantitative Analyses of Normal Tissue Effects in the Clinic.

Development of new immunotherapy treatments in different cancer types

Cancer immunotherapy involves the use of therapeutic modalities that determine a manipulation of the immune system by using immune agents such as cytokines, vaccines, cell therapies and humoral, transfection agents. Immunotherapy of cancer has to stimulate the host's anti-tumor response by increasing the effector cell number and the production of soluble mediators and decrease the host's suppressor mechanisms by inducing tumor killing environment and by modulating immune checkpoints. Immunotherapy seems to work better in more immunogenic tumors. Making a review of literature, the article presents the new immunologic treatments in cancers less presented in the latest conferences, cancers in which, immunotherapy is still under investigation. Bladder cancer was the first indication for which immunotherapy was used in 1970. A promising clinical research in bladder cancer is the use of immune checkpoint inhibitors. Although breast cancer is considered immunologically silent, several preclinical and clinical studies suggested that immunotherapy has the potential to improve the clinical outcomes for patients with breast cancer. Cervical cancer, brain cancer, head and neck cancer and colorectal and esophageal cancers are cancer types for which new immune-based cancer treatments are currently under development. Recent agents used in clinical trials will be described in before mentioned cancers.

Metastatic clear cell renal carcinoma - an unusual response to Temsirolimus in second line therapy

Renal cell carcinoma (RCC) represents 3% of all cancers, with the highest incidence occurring in the most developed countries and representing the seventh most common cancer in men and the ninth most common cancer in women. The understanding of the tumor molecular biology and the discovery of new drugs that target molecular pathways have increased the arsenal against advanced renal cell carcinoma and improved the outcomes in the patients suffering from these affections. Studying the molecular signaling that controls the tumor growth and the progression has led to the development of molecular therapies targeting the vascular endothelial growth factor (VEGF) and mammalian target of rapamycin (mTOR) pathways, resulting in a significant improvement in the overall survival and quality of life. Sunitinib represents an inhibitor of VEGFR 1-3, c-kit, FLT-3 and PDGFR. We present the case of a patient with metastatic clear cell RCC with a treatment effect following sequential VEGF and mTOR inhibitor treatment. Under sunitinib treatment, the patient had a progression free survival (PFS) of approximately 9 months, similar to the PFS observed in clinical trials. Sunitinib was well tolerated by this patient. Temsirolimus, an mTOR inhibitor, is currently only approved for the first-line treatment of mRCC patients with poor prognosis. This study analyzes a treatment effect of second line temsirolimus in a patient with metastatic renal cell carcinoma (mRCC).

Antiangiogenic Treatment in Ovarian Cancer in the Era of Evidenced-Based Medicine

Angiogenesis plays a major role in tumor growth and metastatic spread of cancer, and therefore inhibition of angiogenesis seems a promising therapeutic strategy. In order to grow beyond microscopic size, tumors need a better delivery of nutrients and oxygen so neovascularization must occur. Vascular endothelial growth factor [VEGF] pathway is the most important factor in promoting angiogenesis. This pathway may be blocked by either extracellular interference with VEGF itself (bevacizumab [BEV] or aflibercept), or intracytoplasmic inhibition of VEGF receptor (pazopanib, nintedanib, cediranib, sunitinib and sorafenib). Approximately 97% of ovarian tumors over express the VEGF ligand and this is correlated with early metastases, ascites formation and poor prognosis. The addition of antiangiogenic agents to standard chemotherapy in ovarian cancer is a rational therapeutic option for primary or recurrent ovarian carcinoma but it does not represent a new standard treatment until the subset of patients who benefit the most is identified.

The incidence and risk factors for occurrence of arm lymphedema after treatment of breast cancer

BACKGROUND

The arm lymphedema is reported as being the most frequent late reaction and complication that influences breast cancer patients'€™ quality of life after lymph node dissection and radiotherapy. The aim of the study is to identify the risk factors in arm lymphedema occurrence in breast cancer patients who performed radical conservatory surgery, chemotherapy and radiotherapy.

MATERIAL AND METHODS

We analysed 305 breast cancer patients who underwent treatment in the "Sf. Ap. Andrei"€ Emergency Clinical Hospital, Galati, Radiotherapy and Oncology Department, between the 1st of January 2010 and 31st of December 2012. We tried to find the risk factors for arm lymphedema development after treatment of breast cancer: the association of adjuvant radiotherapy with surgery, chemotherapy,hormonal therapy, number of removed lymph nodes,and number of lymph nodes with metastases, the co-morbid illnesses (obesity, diabetes mellitus and high blood pressure).

RESULTS

Our study evidences that the association of adjuvant radiotherapy, including the lymph node regions, with radical or conservatory surgery with lymph node dissection represents a statistically significant risk factor, with relative risk, RR =1.87, 95%C.I.=1.39-€3.51, p<0.001. The number of removed lymph nodes was found to be a risk factor with statistical significance. For more than 25 removed lymph nodes, the relative risk for arm lymphedema development was RR=1.95(95%C.I. =1.79-4.51) and for 16-25 removed lymph nodes the relative risk, RR = 1.78, 95% C.I. = 1.46 - 3.23. Other analysed risk factors, which did not influence lymphedema development, were: associated chemotherapy or hormonal therapy,presence of co-morbid illnesses.

CONCLUSIONS

The development of arm lymphedema is an unpredictable occurrence that can happen years after axillary surgery.Breast and arm oedema continue to be late reactions that can be reduced by use of biopsy sentinel technique with avoiding of axillary lymph node dissection, when the sentinel lymph node is negative, knowing that lymphedema risk after sentinel lymph node is 5% comparative with lymphedema risk after axillary lymph node dissection which is 16%, by avoiding obesity, and performing modern therapy techniques.

Selecting first-line bevacizumab-containing therapy for advanced breast cancer: TURANDOT risk factor analyses

BACKGROUND

The randomised phase III TURANDOT trial compared first-line bevacizumab-paclitaxel (BEV-PAC) vs bevacizumab-capecitabine (BEV-CAP) in HER2-negative locally recurrent/metastatic breast cancer (LR/mBC). The interim analysis revealed no difference in overall survival (OS; primary end point) between treatment arms; however, progression-free survival (PFS) and objective response rate were significantly superior with BEV-PAC. We sought to identify patient populations that may be most appropriately treated with one or other regimen.

METHODS

Patients with HER2-negative LR/mBC who had received no prior chemotherapy for advanced disease were randomised to either BEV-PAC (bevacizumab 10 mg kg(-1) days 1 and 15 plus paclitaxel 90 mg m(-2) days 1, 8 and 15 q4w) or BEV-CAP (bevacizumab 15 mg kg(-1) day 1 plus capecitabine 1000 mg m(-2) bid days 1-14 q3w). The study population was categorised into three cohorts: triple-negative breast cancer (TNBC), high-risk hormone receptor-positive (HR+) and low-risk HR+. High- and low-risk HR+ were defined, respectively, as having ⩾2 vs ⩽1 of the following four risk factors: disease-free interval ⩽24 months; visceral metastases; prior (neo)adjuvant anthracycline and/or taxane; and metastases in ⩾3 organs.

RESULTS

The treatment effect on OS differed between cohorts. Non-significant OS trends favoured BEV-PAC in the TNBC cohort and BEV-CAP in the low-risk HR+ cohort. In all three cohorts, there was a non-significant PFS trend favouring BEV-PAC. Grade ⩾3 adverse events were consistently less common with BEV-CAP.

CONCLUSIONS

A simple risk factor index may help in selecting bevacizumab-containing regimens, balancing outcome, safety profile and patient preference. Final OS results are expected in 2015 (ClinicalTrials.gov NCT00600340).

Single incision laparoscopic cholecystectomy

BACKGROUND

As surgeons embrace the concept of increasingly less invasive surgery, techniques using only a single small incision have begun to gain traction. Multiple case series managed by a single-incision laparoscopic cholecystectomy (SILC) have been published. The objective of this study is to describe the short-term outcomes of SILC in our institution.

METHODS

A retrospective review was done for 51 patients who underwent SILC between 2009-2012. The operative time, surgical technique, conversion rate, and postoperative complications were reported.

RESULTS

SILC was performed for 51 patients, all women, with a mean age of 35.6 years (range=19-62). Their body mass index(BMI) ranged from 16.8-35.6 kg m2 with a mean of 20.4. Twelve patients (23.52 %) had acute cholecystitis. The mean operating time was 58.6 minutes (range=45-95 min). Incidents were encountered in 6 patients (11.76%) and were related to intraoperative bleeding. There was a single conversion to the standard laparoscopic procedure (1.9%) and in 5 cases an accessory needle grasp was used (9.8%). Two patients (3.9%)presented postoperative complications (wound infections) and the mean hospital stay was 1.6 days.

CONCLUSIONS

SILC is feasible and provides a promising alternative to natural orifice transluminal endoscopic surgery for scarless laparoscopic cholecystectomy. However, routine application of this novel technique requires an evaluation of its safety and cost effectiveness in larger studies.

Involvement of reactive oxygen species in the mechanisms associated with cervical cancer specific treatment

Cervical cancer represents a genuine health issue in Romania.The courses of treatment applied are complex, and the accompanying biochemical mechanisms are yet to be fully understood. Thus, radiotherapy, which induces reactive oxygen species, can lead to failure of treatment in hypoxic tissues,tissues which are difficult to identify due to the small quantity in which these cytotoxic species are produced. As a result, the aim of this paper is to identify the production and role of reactive oxygen species, as well as the manner of activation of endogenous antioxidant defense mechanisms in cervical cancer patients admitted to the Oncologic Institute of Bucharest. To this purpose the biochemical parameters of oxidative stress were identified in 30 patients with cervical tumour localization, prior to surgery. The results obtained have showed that a production of reactive oxygen species is identifiable in these patients, having lipids as a primary target and leading to their peroxidation. The extension of protein oxidative degradation takes place at a much lower value, as well as the activation of endogenous antioxidant defence systems, comparing to our expectations. To conclude,we consider that when the production of active oxygen metabolites takes place in small concentrations, associated with hypoxia, the signals transmitted are towards modifying the phenotype under anaerobic conditions into one activating neo vascularization, angiogenesis initiation, new cell growth and proliferation. The moment that this phase is overcome anew oxidative stress is installed, one potentially destructive for biomolecules essential to life, but also useful for further treatment, such as radiotherapy.

Abstract P6-06-40: Analysis of outcome according to risk factors in the randomized phase III TURANDOT trial evaluating first-line bevacizumab-containing therapy for HER2-negative locally recurrent/metastatic breast cancer (LR/mBC)

Background: The randomized phase III TURANDOT trial compared first-line bevacizumab (BEV) + paclitaxel (PAC) vs BEV + capecitabine (CAP) in HER2-negative LR/mBC [Lang, Lancet Oncol 2013]. At the prespecified interim analysis there was no detectable difference in overall survival (OS; primary endpoint) between treatment groups, but the secondary endpoints of progression-free survival (PFS) and objective response rate (ORR) favored BEV-PAC. We sought to identify patient populations defined by risk factors that may be most appropriately treated with one or other of the regimens.

Methods: Patients with HER2-negative LR/mBC who had received no prior chemotherapy for LR/mBC were randomized to either BEV-PAC (BEV 10 mg/kg d1 & 15 + PAC 90 mg/m2 d1, 8, & 15 q4w) or BEV-CAP (BEV 15 mg/kg d1 + CAP 1000 mg/m2 bid d1-14 q3w). The study population was categorized into three cohorts: triple-negative (TNBC), high-risk hormone receptor-positive (HR+) and low-risk HR+. High-risk and low-risk HR+ were defined, respectively, as having ≥2 vs ≤1 of the following four risk factors: disease-free interval ≤24 months; visceral metastases; prior (neo)adjuvant anthracycline and/or taxane; ≥3 metastatic sites.

Results: Baseline characteristics, efficacy, and safety by treatment arm are summarized below for the three cohorts. Although PFS results in all cohorts favored BEV-PAC, interim OS results showed a trend in favor of BEV-PAC in TNBC patients and in favor of BEV-CAP in low-risk HR+ patients. Grade ≥3 adverse events were less common with BEV-CAP than BEV-PAC in all three cohorts.

 TNBCHigh-risk HR+Low-risk HR+ BEV-PAC (n = 63)BEV-CAP (n = 67)BEV-PAC (n = 146)BEV-CAP (n = 162)BEV-PAC (n = 75)BEV-CAP (n = 50)Median age, years545658576161ECOG PS 0,%756068666366PFS      Events, n (%)50 (79)54 (81)93 (64)125 (77)33 (44)35 (70)Median, months (95% CI)9.0 (7.8-10.7)5.6 (4.9-8.0)11.1 (10.4-13.4)8.3 (7.1-10.7)14.4 (10.4-20.5)11.5 (8.1-16.3)HR (95% CI)a1.37 (0.93-2.02)1.29 (0.98-1.69)1.39 (0.86-2.25)OS      Events, n (%)28 (44)34 (51)50 (34)52 (32)18 (24)11 (22)1-year OS rate,%786380828590HR (95% CI)a1.33 (0.80-2.19)0.97 (0.66-1.43)0.80 (0.38-1.69)Grade ≥3 AEs,%634261516148aBEV-CAP vs BEV-PAC

Conclusion: The simple risk factor index is prognostic for both PFS and OS and may be used to guide treatment choice when selecting BEV-containing therapy, balancing outcome with safety profile and patient preference. Final analysis of OS is expected in 2014.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-06-40.

Monitoring the production of reactive oxygen species in experimental melanoma

HYPOTHESIS

Melanoma is one of the most aggressive forms of skin cancer characterized by malignant proliferation of melanocytes. The role played by reactive oxygen species and free radicals in the pathology of melanoma in humans is widely accepted today.

OBJECTIVE

This paper aims to characterize some types of malignant melanoma obtained experimentally by the inoculation of reference cells for the creation of models and the identification of oxidative stress markers usable for monitoring tumor growth and development.

METHODS AND RESULTS

Mice C57Bl/6. Reference cell lines B16, F1, F10. Inoculation of cells was performed in the upper right flank. Tumors were characterized both anatomically and morphologically. For the biochemical characterization of the oxidative stress, tests were performed to determine lipid peroxides, total albumin thiol groups and total antioxidant response. Tumor volume was measured in dynamic. The fastest development has been observed in type B melanoma. For the F and F10 types, the curves profiles are the same. The results indicate an increase of lipid peroxidation reaction in dynamic tumor evolution, suggesting the malignant associated transformations.

DISCUSSION

These data demonstrate that an alteration of the antioxidant pattern can be detected in the serum of the experimental animals with melanoma, possibly related to the disease status and progression. Our results can be useful in monitoring the tumor evolution and also to highlight the prolonged damage which actions on the normal cells, suggesting the combination of the classical treatments with an adjuvant antioxidant treatment.

Expert opinion 2011 on the use of new anti-resorptive agents in the prevention of skeletal-related events in metastatic bone disease

Bisphosphonates have been a mainstay in the treatment of cancer-related bone disease and have greatly reduced the risk of skeletal complications. More recently, clinical studies suggested additional benefits of denosumab over zoledronic acid in the prevention of skeletal related events. Similar adverse event profiles have been reported for bisphosphonates and denosumab, with infrequent occurrences of osteonecrosis of the jaw with both agents, higher incidence of renal deterioration with zoledronic acid, and higher incidence of hypocalcaemia with denosumab. Based on current evidence, the American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN) guidelines do not recommend one drug class over the other in patients with metastatic bone disease. Denosumab, however, may present advantages over bisphosphonates in patients suffering from chronic renal insufficiency. Further research and growing clinical experience will refine the evidence based on which decisions in daily clinical practice can be taken.

Breast cancer. Screening criteria

Breast cancer is the most frequent type of neoplastic disease in women, amounting to approximately 26% of all annually diagnosed cancers, and representing the second leading cause of female death after pulmonary cancer. Although the prognosis of the disease has improved in recent years, an important number of patients will suffer an evolution of the disease and will die due to this malignancy, which remains resistant to various cytostatic drugs, this being the main cause for therapeutic failure in over 90% of patients with a neoplastic development at this level. As a genic evaluation of the resistance to chemotherapy is difficult to obtain under the current clinical practice conditions, we desired to follow a series of parameters which were easy to evaluate, and which could be correlated with resistance to chemotherapy. Further on, we shall report a clinical case of a patient presenting with chemotherapy resistant breast cancer and unfavourable prognostic factors, in which we determined the biochemical parameters for oxidative stress (serum monoaldehyde a marker of lipid peroxidase, serum ceruloplasmin whose activation stimulates an overproduction of reactive species of oxygen, plasmatic albumin thiol groups important components of antioxidant defence, total serum antioxidants which measure the ability of the plasma to resist in face of the effects of reactive species of oxygen), correlated with an apoptosis evaluation (scheduled cellular death) performed on fresh tumoral tissue.Histopathological, immunohistochemical and flowcytometry data correlated. Even if the results obtained indicate a high oxidative stress status and a diminished capacity of endogenous antioxidant defence, it appears that this oxidative stress alone was not potent enough to induce the desired tumoral cytotoxicity.

Perforation of Meckel's diverticulum by foreign body, a rare complication

Meckel's diverticulum is a congenital disorder that results from an incomplete obliteration of the vitelline duct. Meckel's diverticulum may give rise to bleeding, intestinal obstruction and inflammation; however, its perforation by a foreign body is an extremely rare life-threatening complication. We report ona 37-year-old male presenting symptoms and signs of acute abdomen with an initial suspicion of acute appendicitis.However, the right diagnosis was made only during exploratory laparoscopy when the appendix was found to be normal,whereas Meckel's diverticulum was found to be inflamed and perforated by a chicken bone. The patient was treated successfully with laparoscopic resection of the diverticulum, and had an uncomplicated postoperative course.

Abstract LB-177: First-line bevacizumab (BEV) + chemotherapy for hormone receptor-positive metastatic breast cancer (mBC): Subgroup analysis of the open-label non-inferiority TURANDOT phase III trial

Purpose: The TURANDOT interim efficacy analysis showed no difference in OS (primary endpoint) between BEV + paclitaxel (PAC) vs BEV + capecitabine (CAP) as first-line therapy for HER2-negative mBC; progression-free survival (PFS) and response rate (RR) were superior with BEV–PAC [Lang, Lancet Oncol 2013]. We report post-hoc subgroup analyses in 433 pts with estrogen and/or progesterone receptor-positive (ER/PgR+) mBC, including subsets with aggressive disease characteristics.

Methods: Pts with HER2-negative mBC who had received no prior chemotherapy for mBC were randomized to BEV-PAC (BEV 10 mg/kg d1 & 15 + PAC 90 mg/m2 d1, 8, & 15 q4w) or BEV-CAP (BEV 15 mg/kg d1 + CAP 1000 mg/m2 bid d1-14 q3w) until progression or unacceptable toxicity. Endocrine therapy was not allowed during study therapy.

Results: Baseline characteristics in the BEV-PAC (n=221) and BEV-CAP (n=212) arms, respectively, were: median age 60 vs 59 y; visceral metastases 65% vs 74%; &gt;10 cm sum of largest diameter (SLD) of target lesions 22% vs 20%; &gt;5–10 cm SLD 22% vs 28%; prior hormonal therapy for mBC 27% vs 26%. At data cut-off (Sep 2011, median follow-up 18.4 mo), BEV therapy was ongoing in 11% vs 10% of pts. Hormone therapy was administered after stopping study therapy in 33% vs 29% of pts. The OS hazard ratio (HR) after events in 30% was 0.92 (95% CI 0.65–1.30). The 1-year OS rate was 82% with BEV-PAC vs 84% with BEV-CAP. PFS and RR both favored BEV-PAC (PFS HR: 1.31 [95% CI 1.03–1.68; p=0.03], median 12.7 vs 8.4 mo; RR 42% vs 30% –12% difference, 95% CI –21 to –3; p=0.007). Grade (G) ≥3 treatment-emergent adverse events (AEs) occurred in 61% (8% G4, 3% G5) vs 50% (7% G4, 3% G5) of pts, respectively. AEs were consistent with previous data.

CharacteristicSubgroupOS HRa (95% CI)ECOG performance status0 (n = 285)0.93 (0.58-1.51)1/2 (n = 145)b0.97 (0.60-1.59)Disease-free interval, moNonec (n = 104)b0.87 (0.41-1.85)≤12 (n = 14)b0.88 (0.23-3.30)&gt;12 (n = 315)0.96 (0.64-1.45)SLD in target lesions, cm≤5 (n = 140)0.93 (0.52-1.69)&gt;5 (n = 197)b0.94 (0.58-1.51)Visceral metastasesYes (n = 301)b0.92 (0.62-1.36)No (n = 132)0.92 (0.44-1.90)Lymph node metastasesYes (n = 232)b1.05 (0.67-1.64)No (n = 201)0.81 (0.47-1.40)aBEV-CAP vs BEV-PACbAggressive disease characteristicscPts who either received no therapy or did not respond to therapy for primary breast cancer

Conclusion: Within the caveats of post-hoc subgroup analyses, no subset with aggressive disease characteristics was found to have a relevant OS advantage for either regimen, consistent with findings in all ER/PgR+ pts.

Citation Format: Zsuzsanna Kahán, Lubos Petruzelka, Alexandru Eniu, Rodica Anghel, Krassimir Koynov, Damir Vrbanec, Istvan Lang, Silke Ahlers, Thomas Brodowicz, Christoph Zielinski. First-line bevacizumab (BEV) + chemotherapy for hormone receptor-positive metastatic breast cancer (mBC): Subgroup analysis of the open-label non-inferiority TURANDOT phase III trial. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr LB-177. doi:10.1158/1538-7445.AM2013-LB-177

Laparoscopic treatment of perforated duodenal ulcer -- a multicenter study

AIM

The aim of this study is to evaluate the results of the laparoscopic treatment of perforated duodenal ulcer performed in 6 Romanian surgical centres with experience in the field of laparoscopic surgery.

MATERIAL AND METHOD

Between 1996 and 2005, 186 patients with perforated duodenal ulcer were operated on in the centers participating in this retrospective study, all patients being ASA I-II. Thirty-nine patients (20.0%) presented mild peritonitis, 120 (64.5%) medium peritonitis and 27 (15.5%) severe (20.0%) simple suture was performed, in 110 (59.1%) suture with epiplonoplasty, for 1 (0.5%) only epiplonoplasty and 1 (0.5%) underwent excision of the perforation and suture.

RESULTS

The operative time was between 30-120 minutes, with an average of 75 minutes. No death was noted. Average hospitalization time was 6 days, with periods varying between 3 and 18 days. Postoperative complications included: 5 patients (2,6%) presented infections of the abdominal walls, 1 patient (0.5%) duodenal fistula, 1 patient (0.5%) intra-abdominal abscess, 1 patient (0.5%) a superior digestive hemorrhage by "mirrored ulcer" and 1 patient (0.5%) duodenal stenosis 6 months after operation. The patients were administered 50% less analgesics, used 70% less dressings, 30% less antibiotics and had 60% less complications in comparison with those operated by the classical approach.

CONCLUSION

The laparoscopic approach of perforated duodenal ulcer constitutes the first choice for patients without important co-morbidities, allowing a quick recovery and a significant reduction in the consumption of analgesics, antibiotics and dressing materials.