Multi-Institutional Validation of the Recursive Partitioning Analysis for Overall Survival in Patients Undergoing Spine Radiosurgery for Spine Metastasis

PURPOSE/OBJECTIVE(S)

The recently published spine radiosurgery (sSRS) recursive partitioning analysis (RPA) for overall survival (OS) separated patients into 3 distinct prognostic groups. We sought to externally validate this RPA using 3 separate multi-institutional datasets.

MATERIALS/METHODS

A total of 444 patients were utilized to develop the recently published sSRS RPA predictive of OS in patients with spine metastases. The RPA identified three distinct prognostic classes. RPA Class 1 was defined as KPS >70 and controlled systemic disease (n = 142); RPA Class 2 was defined as KPS>70 with uncontrolled systemic disease or KPS ≤70, age ≥54 and absence of visceral metastases (n = 207); RPA Class 3 was defined as KPS ≤70 and age <54 years or KPS≤70, age ≥54 years and presence of visceral metastases (n = 95). We utilized data from 3 large tertiary care centers to independently validate this RPA. Data from each institution was utilized independently to validate the RPA to minimize confounding based on institutional differences in patient selection. A total of 1,184 patients (221 patients from institution A, 749 institution B, and 214 from institution C) were in the validation cohort and were divided based on their RPA Class. Kaplan-Meier method was used to estimate OS and log-rank test was used to compare OS between RPA classes.

RESULTS

In each of the validation cohorts, the median OS was 19.9 months (institution A), 11.0 months (institution B), and 24.4 months (institution C). The patient distribution into RPA classification based on Institution A/B/C was, Class 1 (19.4%, 15.1%, 50.5%), Class 2 (74.7%, 57.7%%, 37.9%), and Class 3 (5.9%, 27.2%%, 11.2%), respectively. The median OS for patients in the validation cohort at Institution A/B/C based on RPA class was Class 1 (54 months, 27.1 months, 50.0 months), Class 2 (15.9 months, 13.0 months, 15.1 months) and Class 3 (6.9 months, 3.5 months, 6.1 months), respectively. Patients in RPA Class 1 had a significantly better OS compared to those in Class 2 of the each of the three external institution validation cohorts (p<0.01). Similarly, patients in RPA Class 2 had a significantly better OS compared to those in Class 3 (p<0.01).

CONCLUSION

The external datasets from three large institutions independently validated the spine SRS RPA successfully for OS in patients undergoing sSRS for spinal metastases. This is the first RPA for OS to have been externally validated using multiple large datasets. Based on this validation, upfront spine SRS is strongly supported for patients in RPA Class 1 and Class 2 and is also cost effective with median OS >11 months for these patients. Patients in RPA Class 3 would benefit most from upfront conventional radiotherapy given their poor expected survival. Given successful external validation, this RPA helps guide physicians to identify those patients with spinal metastases who most benefit from sSRS.

Dosimetric Impact of Radiolucent Carbon Fiber Hardware for Post-Operative Spine Stereotactic Body Radiation Therapy

PURPOSE/OBJECTIVE(S)

The spine is the most common site of osseous metastases. In the non-operative setting, there is growing support for stereotactic body radiation therapy (SBRT) over conventional radiation therapy for improved pain relief and local control. Hybrid therapy consisting of separation surgery and post-operative SBRT is considered in patients with biomechanical instability and epidural cord compression. Surgery traditionally requires titanium (Ti) implants, which introduce artifacts on post-operative imaging in addition to increased uncertainty and beam attenuation. Use of radiolucent carbon fiber reinforced polyetheretherketone (CFR-PEEK) hardware has been shown to provide safe and comparable surgical outcomes as compared to Ti. Our primary objective is to assess the dosimetric impact of Ti versus carbon fiber implants in spine SBRT.

MATERIALS/METHODS

Single institution retrospective series of post-operative spine SBRT from 2019-2020. Re-irradiation cases were excluded. The electronic medical record and treatment planning systems (TPS) were queried. Dosimetric analyses compared original Ti plans with reoptimized plans, replacing Ti hardware electronic density with carbon fiber. Maintaining clinical goals, dose calculations were performed in a treatment planning system using a collapsed cone algorithm. All treatments used step and shoot intensity modulated radiation therapy to avoid beam angles with significant metal along the beam path. Metallic artifacts were contoured and assigned the appropriate tissue density. A D'Agostino-Pearson test was used to assess data for normality. We used paired Student's t-tests to compare three dosimetric outcomes in the setting of Ti and carbon fiber implants. Planning target volume (PTV) coverage was represented by the volume receiving at least the prescribed dose (%), the maximum point dose (dmax, cGy) to the spinal cord planning risk volume (PRV, 2 mm margin), and the overall hot spot intensity (plan dmax).

RESULTS

A series of 14 consecutive SBRT cases were evaluated (dose 27-30 Gy in 3-5 fractions). All dosimetric outcomes were normally distributed (p>0.05). We found a statistically significant difference in PTV coverage between the original SBRT treatment plans with Ti hardware (mean 85.1 ± 7.9%) and reoptimized carbon fiber hardware (87.3 ± 6.6%; p = 0.002). There was no significant difference in mean spinal cord PRV dmax between Ti and carbon fiber plans (1846 ± 483 cGy vs. 1842 ± 495 cGy; p>0.05). We observed a nonsignificant increase in mean overall dmax from 3932 ± 416 cGy in the Ti cohort to 4111 ± 906 cGy in the carbon fiber cohort (p>0.05).

CONCLUSION

Carbon fiber implants provide a significant increase in SBRT target coverage, without impacting the overall plan and spinal cord PRV dmax in this retrospective series. In addition to improved post-operative imaging and reduced uncertainty, carbon fiber hardware may offer dosimetric advantages as compared to traditional Ti spinal implants, and warrants further investigation in a larger cohort.

Craniospinal Irradiation for CNS Leukemia: Rates of Response and Durability of CNS Control

PURPOSE/OBJECTIVE(S)

Craniospinal irradiation (CSI) is used in the management of leukemia patients with central-nervous-system (CNS) involvement, though the data on response and local control are limited. Given the radioresponsiveness of leukemia, we hypothesized that response to CSI would be high, but CNS control would be influenced by control of systemic disease.

MATERIALS/METHODS

This retrospective, single-institution analysis included consecutive pediatric and adult patients between 2009-2021 with leukemia that underwent CSI for CNS involvement, defined as presence of blasts (i.e., >0%) on CSF flow cytometry. Endpoints included CNS response rate (RR), CNS local recurrence (LR), progression-free survival (PFS), and overall survival (OS), which were estimated from start of CSI. The probability of CNS LR was summarized using a cumulative incidence estimate, where death without LR was considered a competing risk. The probabilities of OS and PFS were obtained using Kaplan-Meier estimates.

RESULTS

Among the 39 eligible patients (43% AML, 49% ALL, 8% blast-phase CML), most were male (59%). All had CSF confirmation of disease. Median age at CSI was 31 years (range 7-67). CSI (protons 54%, photons 46%) was utilized early within the CNS disease course (median 0 CNS relapses prior to CSI). Twenty-five patients (64%) received CSI immediately prior to a stem-cell transplant (SCT), of which 21 (84%) had TBI conditioning to a median dose of 12 Gy (range 2-13.2). Patients treated with CSI alone received a higher CSI dose (median 18 Gy; range 10.8-24) than those treated with SCT consolidation (median 12 Gy; range 10.8-24). Fifteen patients had CSF-positive disease immediately prior to CSI; all 14 of those assessed for response (RR 100%) had confirmed clearance of blasts at a median of 23 days (range 7-197) from CSI start. With a median follow-up of 48 months (range 0.4-123) for survivors, 2-year PFS and OS estimates were 32% and 43%, respectively. Only 5 CNS relapses were noted (2-year CNS LR of 14%). All CNS relapses either occurred after (n = 4) or concurrently (n = 1) with a systemic relapse. In Cox regression univariate models, age, sex, time to CNS disease, positive CSF immediately prior to CSI, and SCT did not show demonstrable evidence of association with CNS LR. However, systemic relapse after CSI (HR 5.9, 95% CI 2.5-13.8, P<0.0001) and systemic disease at the time of CSI (HR 3.9, 95% CI 1.6-9.5, P = 0.003) were associated with higher risk of CNS LR. No grade-3+ acute toxicity was seen during CSI.

CONCLUSION

CSI is a well-tolerated and effective treatment option for patients with CNS leukemia. Though CNS local recurrence was modest, there was a high risk of systemic relapse and/or death. Control of systemic disease, both before and after CSI, may be important for CNS local control, and raises consideration that CNS recurrence may reflect reseeding from the systemic space.

5-Year Renal Function Outcomes after SABR for Primary Renal Cell Carcinoma: A Report from the International Radiosurgery Oncology Consortium of the Kidney (IROCK)

PURPOSE/OBJECTIVE(S)

Renal cell carcinoma (RCC) presents uncommonly in patients with a congenital solitary kidney or prior contralateral nephrectomy. The objective of this study was to compare renal function outcomes of stereotactic ablative body radiotherapy (SABR) in patients with solitary vs. bilateral kidneys.

MATERIALS/METHODS

Patients with primary RCC with ≥2 years of follow-up at 12 participating International Radiosurgery Consortium for Kidney (IROCK) institutions were included. Patients with upper tract urothelial carcinoma or metastatic disease were excluded. Renal function was measured by estimated glomerular filtration rate (eGFR). For patients where eGFR was not recorded, Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation was used to estimate eGFR based on known creatinine. Baseline characteristics and renal function outcomes were compared between solitary vs. bilateral kidneys. Multivariable logistic regression was used to identify factors predictive of eGFR decline ≥ 15 mL/min and any eGFR increase evaluated at 1-year post-SABR.

RESULTS

One hundred and ninety patients with solitary (n = 56) or bilateral kidneys (n = 134) underwent SABR and were followed for a median of 5.0 years (IQR: 3.4-6.8). Pre-SABR eGFR (mean ± SD) was similar in patients with solitary (61.1 ± 23.2 mL/min) vs. bilateral kidneys (58.0 ± 22.3 mL/min, p = 0.324). Mean tumor size was 3.70 ± 1.40 cm in solitary and 4.35 ± 2.50 cm in bilateral kidneys (p = 0.026). After SABR, an initial compensatory increase in eGFR was observed in both cohorts (22.7% solitary and 17.7% bilateral at 1 year). This compensatory increase persisted in patients with bilateral but not a solitary kidney (10.3% vs. 0% at 3-years and 21.1% vs. 0% at 5-years, respectively). At 5-years post-SABR, eGFR decreased by -14.5 ± 7.6 in solitary and -13.3 ± 15.9 mL/min in bilateral kidneys (p = 0.665). At all timepoints assessed, there were no significant differences in eGFR decline between solitary vs. bilateral cohorts (all p > 0.05). There were also no significant differences in post-SABR end-stage renal disease (7.1% vs. 6.7%) or dialysis (3.6% vs. 3.7%) in solitary vs. bilateral, respectively. Multivariable analysis demonstrated that increasing tumor size (OR per 1 cm: 1.57; 95% CI: 1.14-2.16, p = 0.006) and baseline eGFR (OR per 10 mL/min: 1.30; 95% CI: 1.02-1.66, p = 0.034) was more likely to be associated with eGFR decline ≥ 15 mL/min. There was no significant association between solitary vs. bilateral kidney and eGFR decline (OR: 1.22; 95% CI: 0.45-3.34, p = 0.693).

CONCLUSION

There was no observed difference between renal function outcomes in patients with a solitary vs. bilateral kidneys. While larger tumor size may increase the risk of eGFR decline post-SABR, treatment of a solitary kidney does not appear to increase the risk of renal dysfunction long-term.

Survey of current practices from an international task force for gynecological stereotactic ablative radiotherapy

Background

Stereotactic Ablative Radiotherapy (SABR) is an effective treatment that improves local control for many tumours. However, the role of SABR in gynecological cancers (GYN) has not been well-established. We hypothesize that there exists considerable variation in GYN-SABR practice and technique. The goal of this study is to describe clinical and technical factors in utilization of GYN-SABR among 11 experienced radiation oncologists.

Materials and methods

A 63 question survey on GYN-SABR was sent to 11 radiation oncologists (5 countries) who have published original research, conducted trials or have an established program at their institutions. Responses were combined and analyzed at a central institution.

Results

Most respondents indicated that salvage therapy (non-irradiated or re-irradiated field) for nodal (81%) and primary recurrent disease (91%) could be considered standard options for SABR in the setting of inability to administer brachytherapy. All other indications should be considered on clinical trials. Most would not offer SABR as a boost in primary treatment off-trial without absolute contraindications to brachytherapy. Multi-modality imaging is often (91%) used for planning including PET, CT contrast and MRI. There is a wide variation for OAR tolerances however small bowel is considered the dose-limiting structure for most experts (91%). Fractionation schedules range from 3 to 6 fractions for nodal/primary definitive and boost SABR.

Conclusions

Although SABR has become increasingly standard in other oncology disease sites, there remains a wide variation in both clinical and technical factors when treating GYN cancers. Nodal and recurrent disease is considered a potential indication for SABR whereas other indications should be offered on clinical trials. This study summarizes SABR practices among GYN radiation oncologists while further studies are needed to establish consensus guidelines for GYN-SABR treatment.

Abstract P4-16-10: Bone health in young women with breast cancer

Introduction:

There are limited data and consensus regarding bone mineral density (BMD) monitoring, and management of bone loss in younger women with breast cancer (BC). Adjuvant endocrine therapy for estrogen receptor positive (ER+) BC may include ovarian function suppression (OFS) plus use of aromatase inhibitors (AIs) for 5-10 years, both of which contribute to bone loss. The WHO risk prediction tool FRAX does not include BC or AI use as independent risk factors in its calculation thus underestimating risk of fracture. This study aims to evaluate current screening and management of bone health in young women with BC.

Methods:

A retrospective, IRB-approved chart review was performed in consecutive women ≤40 with BC diagnosed at Loyola University Chicago Medical Center between 01/01/2015 and 12/13/17. Demographic data, BC treatment, and factors contributing to secondary causes of bone loss were collected through 4/1/18. A descriptive analysis included summary values for all categorical and continuous risk factors.

Results:

BC ≤40yrs was identified in 136 women; 18 were excluded due to missing data. The analysis was performed on 118 patients (pts). Mean pt age was 34.6 yrs (SD 4.7). Stage at diagnosis included: stage 0 = 9 (7.6%), stage 1 = 26 (22%), stage 2 = 44 (37.3%), stage 3 = 23 (19.5%), stage 4 = 7 (5.9%), unknown = 9 (7.6%). Seventy-nine (67%) had ER+ BC; 32 (27.1%) had HER2-positive disease. The majority of pts (101, 85.6%) received chemotherapy in their treatment plan. Menopause was documented in 69 (59.0%) pts. Goserelin was used in 31 pts (44.9%), oophorectomy in 17 (24.6%), both in 5 (7.2%). Tamoxifen was used in 44 (55.7%) ER+ pts; 34 (43.0%) received an AI, and 18 (22.8%) received sequential tamoxifen and AI. 25 Hydroxy-Vitamin D (25 OHD) levels were checked in 61 (51.7%); 43 (70.5%) had levels &lt;30 ng/ml; 24 (55.8%) received vitamin (vit) D supplementation. There was no difference in the 25 OHD in pre- and post-menopausal women (p=0.64). Pts with vit D deficiency had a median BMI of 26.8 vs 23.8 in those with sufficient vit D levels (exact p=.049). Secondary diagnoses contributing to low BMD were identified in 14 (11.8%). Dual energy xray absorptiometry (DXA) scans were checked in 23 pts (19.7%), 18 of whom were post-menopausal. At the femur, 0 pts had a z-score (age-matched standard deviation) of ≤-2.0, 9 pts (39.1%) had a score between 0 to -2.0. At the lumbar spine, 1 pt (4.3%) had a z-score ≤-2.0, 9 pts (39.1%) had a z-score between 0 to -2.0. No T-scores were in the osteoporosis range; 11 pts had T-scores at both femur and lumbar spine in the osteopenia range. The median 10 yr probability of a major osteoporotic fracture (FRAX score) was 1.9% (1.6-2.7%); the median 10 yr probability for hip fracture was 0.1% (0.10-0.20%). There were no differences in FRAX scores between pre- and post-menopausal women. No fractures were reported in the time period studied. Anti-resorptive therapy was used only in patients with metastatic bone disease.

Conclusions:

25 OHD and DXA scans are not routinely checked in younger women diagnosed with BC. Vit D deficiency and evidence of bone loss is prevalent in those pts who do undergo testing. Further research and guidelines are necessary to address management of bone health in young women with BC to minimize future fracture risk and morbidity.

Citation Format: Wendell KB, Nadeem S, Martin B, Camacho PM, Albain KS, Robinson P, Lo SS. Bone health in young women with breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-16-10.

Abstract P1-12-04: Carboplatin, nab-paclitaxel and bevacizumab as first-line treatment for metastatic breast cancer

Background: Bevacizumab added to weekly paclitaxel resulted in improved progression free survival (PFS) and objective response rates (ORR) compared to weekly paclitaxel alone. Nab-paclitaxel and the platins are active in MBC. We conducted an efficacy and safety study of carboplatin, nab-paclitaxel and bevacizumab.

Methods: A phase II open label prospective multi-site study enrolled patients (pts) who had measurable MBC according to RECIST 1.1 criteria and no prior chemotherapy for advanced disease. The primary endpoint was PFS with secondary endpoints of overall survival (OS), ORR, and safety. Pts initially received carboplatin AUC 6 day 1, 22,43, plus weekly nab-paclitaxel 100mg/m2 and bevacizumab 15mg/m2 day 1,22,43 of a 56 day cycle. This was later changed to carboplatin AUC 6 day 1, nab-paclitaxel 100mg/m2 day 1,8,15, and bevacizumab 10mg/m2 day 1,15 of a 28 day cycle. Thirty-two pts were required to detect an increase in median PFS from 6.7 to 10.5 mo with 80% power based on a one-sided p = 0.05. Kaplan–Meier analyses estimated PFS and OS. The log rank test was used for the comparison of survival curves between pts with triple negative MBC (TNBC) and pts with non-TNBC.

Results: Thirty-two pts were enrolled between 2/2008 and 11/2011 by 1 academic and 5 community oncology practices. Two pts were ineligible due to non-measurable disease and not included in the response analyses. The median age was 58 years (range 35–81), 22 pts (69%) had an ECOG PS 0, 9 (28%) had a PS 1, 1 (3%) PS 2. Twenty-four (75%) pts had ER+ disease, 7 (22%) had TNBC, 1 (3%) had ER-HER2+ disease not eligible for trastuzumab-based therapy. Metastatic sites were bone (26%), liver (18%), loco-regional (16%), and lung (12%). One pt (3%) had bone and loco-regional disease only, 19 (59%) had visceral dominant disease. The median number of weeks on treatment was 28.9 (range 5–131). The median PFS in all pts was 13.6 months (mo) (95% CI 11.2–21.9), with a median OS of 26.8 mo (95% CI 13.3–41.2). The ORR (2 CR and 18 PR) was 66.7% (CI 47.2–82.7). There also were 6 (20%) unconfirmed PR and 3 (10%) stable disease, resulting in a clinical benefit rate of 96.7% (CI 82.78–99.92). There was no significant difference in PFS (median 13.6 vs 16.1mo, p = 0.37) or OS (median 13.6 vs 26.8mo, p = 0.32) in pts with TNBC versus non-TNBC disease. The most common toxicities of any grade (gr) include neutropenia and thrombocytopenia in 24 pts (75%) each, leukopenia and fatigue in 17 pts (53%) each, anemia in 15 (47%), and neuropathy in 10 (31%). Gr 4 neutropenia was seen in 7 pts (22%) without febrile neutropenia, and gr 4 thrombocytopenia occurred in 6 (19%). There were no pts with gr 4 sensory neuropathy. All pts required chemotherapy dose delays, 15 (47%) had chemotherapy dose reductions.

Conclusions: The carboplatin, nab-paclitaxel and bevacizumab combination is highly effective with good tolerance in first line MBC. As the role of anti-angiogenic therapy in first line metastatic breast cancer is being clarified, this would be an attractive regimen to test in the (neo)adjuvant setting and together with novel molecular targeted agents.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-12-04.

Abstract PD10-02: Metabolic syndrome and recurrence within the 21-gene recurrence score assay risk categories in lymph node negative breast cancer

Background: The incidence of the metabolic syndrome (MS) has been increasing in the United States and elsewhere. The interaction of MS with breast cancer (BC) incidence, tumor biology and outcomes are under study. We hypothesized that the presence of MS would predict BC recurrence to a variable degree across the diverse BC biology as defined by the risk categories of the 21-gene recurrence score (RS) assay.

Patients and Methods: We studied consecutive patients (pts) with newly diagnosed, estrogen receptor (ER) positive, lymph node (LN) negative BC treated in our institution between 2006–2011 who had a 21-gene RS assay done on their tumors. All pts were treated with standard systemic and local therapy. The electronic medical record was queried for key diagnoses including MS and its constituent parts. The WHO definition was used to categorize pts as having MS defined as diabetes mellitus (DM) or glucose intolerance, plus at least 2 of the following: hypertension (HTN), dyslipidemia (HL), central obesity and microalbuminemia. Tumor characteristics including Ki67 index, grade, tumor size, HER2/neu status; and pt characteristics including age, race, menopausal status, body mass index were recorded. The association of MS and the tumor and patient characteristics with the RS tertiles of low, intermediate and high risk was analyzed.

Results: We identified 332 pts, median age 62 years, of whom 88 (27%) had MS. There was no significant association between the MS and any of the patient or tumor variables including the 21-gene RS assay, except for race (p = 0.004). Eleven of 21 (52%) African-American women had MS, 68 of 284 (24%) Caucasian women had MS, and 9 of 21 (43%) others including Hispanic and Asian women had MS. However, there was a significant association between recurrence and MS (p = 0.0002) independent of other factors. Of the 21 pts who recurred, 13 (61.9%) had MS. There was an association of recurrence and MS within RS tertiles. For pts with low risk scores, 7/44 (15.9%) with MS vs. 1/126 (0.79%) without MS had recurrence (p = 0.0003). For pts with intermediate risk scores, 5/30 (16.67%) with MS vs. 4/83 (4.82%) without MS had recurrence (p = 0.05). For patients with high risk scores, 1/9 (11.11%) with MS vs. 2/15 (13.33%) without MS had recurrence (p = 1).

Conclusion: MS is an independent risk factor for BC recurrence among women with LN negative, ER positive BC treated with standard adjuvant therapy. There is a striking impact of MS on recurrence in pts with tumor biologies defined by low (and to a lesser degree) intermediate risk 21-gene RS assay scores. However, there is no difference in recurrence risk by MS among those pts with high RS. This implies that interventions directed at modifying MS in newly diagnosed pts with early BC may potentially favorably impact survival in those with specific tumor biologies as defined by multigene assays. Thus, long-term prospective studies should be conducted to further evaluate both the short and long term effects of MS on BC outcomes.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD10-02.

Ultrasound-guided thrombin injection for pseudoaneurysms: a case series at a local hospital

Post-catheterization pseudoaneurysms are increasingly prevalent due to widespread use of endovascular procedures. Ultrasound-guided thrombin injection has emerged as a treatment of choice for these pseudoaneurysms. We review our experience performing this procedure for a series of cases from 2007 to 2010 with different clinical manifestations at a single hospital in Hong Kong. We achieved a high technical success rate with no complications.

Factors associated with recurrence within 2 years after curative surgery for gastric adenocarcinoma

BACKGROUND

Despite curative surgery for gastric cancer, many patients die of recurrent cancer. Few studies have investigated the time to recurrence after curative resection for gastric cancer.

METHODS

Data were collected prospectively between December 1987 and December 2006. A total of 1,549 patients underwent curative resection of adenocarcinoma of the stomach at Taipei Veterans General Hospital. Among them, 419 patients had recurrence; they were divided into early recurrence (<2 years) and late recurrence (≥2 years). The clinicopathological characteristics, survival time after recurrence, and recurrence patterns were compared between the two groups.

RESULTS

Multivariate analysis showed that stage III gastric cancer patients with early recurrence had larger tumors and more lymph node metastasis than patients with late recurrence, while no difference between early and late recurrence was observed in stage I and II patients. Early recurrence was associated with more distant metastasis than was late recurrence. Patients with advanced TNM stage tended to die within 2 years after recurrence.

CONCLUSIONS

Gastric cancer patients with larger tumors and more lymph node metastasis tended to have early recurrence, especially stage III patients. Advanced TNM stage was associated with early cancer death after recurrence.

Peritoneal recurrence in serosa-negative gastric adenocarcinoma after curative surgery

BACKGROUND/AIMS

The rate of recurrence increases in proportion to the degree of tumor depth, even after curative resection for gastric adenocarcinoma. Serosal exposure is considered as an important risk factor of peritoneal recurrence. However, some patients with serosa-negative cancer were found to have peritoneal recurrence. There are few reports concerning risk factors of peritoneal recurrence in serosa-negative gastric adenocarcinoma. The aim of this study is to evaluate the incidence and risk factors of peritoneal recurrence in serosa-negative gastric adenocarcinoma after curative resection.

METHODOLOGY

Total 1128 serosa-negative gastric cancer patients (574 pT1, 251 pT2, 303 pT3) diagnosed as gastric adenocarcinoma that underwent R0 resection from 1988 to 2005 were enrolled.

RESULTS

Peritoneal recurrence was observed in 50 (4.4%) patients, including 3 pT1, 3 pT2 and 44 pT3 patients. The incidence of peritoneal recurrence increased significantly with tumor invading subserosa (pT3). Multivariate analysis showed that the independent risk factor of peritoneal recurrence was tumor depth.

CONCLUSIONS

The incidence of peritoneal recurrence in serosa-negative cancer is low, and tumor depth is a significant risk factor. We should be aware of peritoneal recurrence during follow-up, especially for patients with subserosal tumor invasion.

Risk factors and management of anastomotic leakage after radical gastrectomy for gastric cancer

BACKGROUND/AIMS

Radical gastrectomy remains the primary treatment for gastric cancer without distant metastasis. However, anastomotic leakage and extended lymph node dissection might cause additional morbidity and related mortality.

METHODOLOGY

From January 1988 to December 2004, 2076 patients with gastric cancer underwent radical gastrectomy at Taipei Veterans General Hospital. The risk factors for anastomotic leakage, including clinicopathological factors, operative procedures, combined organ resection, operating time, blood loss, and associated disease, were analyzed. The various methods used to measure anastomotic leakage and the clinical courses of different sites of anastomotic leakage were compared.

RESULTS

The overall complication rate was 18.7% and the incidence of anastomotic leakage was 2.7% (n=57). The anastomotic leakage-related mortality rate was 21.1% (n=12). Older age (> or =65 years), longer operating time, more blood loss, and co-morbidities were the precipitating factors. Adequate drainage was the treatment approach used for anastomotic leakage. The incidence of anastomotic leakage was reduced during the later period of the study (3.4% vs. 1.8%).

CONCLUSION

Only in an institute with a well-established training program and high volume of gastric cancer patients can we improve the surgical skills and accumulate the experiences with management of anastomotic leakage that make radical gastrectomy safer.

Abstract PD05-12: Combination of Notch Inhibitor MK-0752 and Endocrine Therapy for Early Stage ERα + Breast Cancer in a Presurgical Window Pilot Study

Background: Breast tumor initiating cells (TIC) use Notch receptors/ligands with other pathways for self renewal, resulting in tumor proliferation and progression. We showed that Notch inhibition with gamma secretase inhibitors (GSI) potentiates the effects of tamoxifen (tam) in xenografts (Rizzo et al. Cancer Res 2008). It is unknown whether GSIs plus endocrine therapy result in modulation of Notch and other proliferation markers in human breast cancer. Our objective was to add short exposure of the GSI MK-0752 to ongoing tam or letrozole (letr) during the presurgical window to determine 1) feasibility, 2) safety/tolerance, and 3) impact on biomarkers. We report the initial cohort of this pilot study (ClinTrials. gov NCT00756717).

Methods: Patients (pts) with early stage ERα + breast cancer were treated with 25 days of tam or letr. On day 15 MK-0752 was added to endocrine therapy (350 mg orally 3 days on, 4 days off, 3 days on), with definitive surgery day 25. Formalin fixed, paraffin embedded biopsies were obtained at baseline, day 14 and final surgery, with histologic confirmation of tumor content &gt;50% and RNA extraction by standard methods. Q-PCR was done for Notch1, Notch3, Notch4, Deltex, Jagged1, c-myc, HEY1, HEY2, HES1, PS2, C-Myc, Cyclin A2, NOXA (pro-apoptotic protein), Ki67, Dicer-1, RPL13 (internal control). Ct averages for 3 replicates were used and mRNA levels were calculated by the 2ΔΔCt method. Baseline gene expression levels were used as comparators for days 14 and 25 levels in each pt. The first cohort of 10 pts was analyzed to determine if enough signals were present to justify expanding the cohort at this dose to 20 pts and possibly test a second cohort on an alternate MK-0752 dose/schedule. Results: The initial cohort of 10 pts completed all therapy (4 tam, 6 letr), all biopsies and definitive surgery on schedule. One other pt withdrew prior to starting MK-0752 due to hypertension. Toxicity was minimal: grade 1 periorbital edema/cough, nausea, and axillary paresthesias in 1 pt each; grade 1 facial rash, 2 pts; and grade 2 fatigue, 1 pt. There was no diarrhea or surgical complications. Significant changes occurred in molecular marker levels after MK-0752 plus tam/letr (day 25) vs. end of tam/letr alone (day 14) as follows: Ki67 mRNA decreased in 9/10 pts; Notch4 decreased, 10/10; NOXA increased, 6/10; and Notch1 decreased, 6/10. Other markers showed inter-individual variations and will be presented, along with results of the global gene expression profiling (in progress). Conclusions: The addition of a short exposure of the GSI MK-0752 to ongoing endocrine therapy was feasible, safe, and well tolerated in pts with ERα + early breast cancer prior to definitive surgery. It results in anti-proliferative and pro-apoptotic effects at the molecular level. Notch4, which plays a key role in breast TIC, was the most consistent molecular marker of response in this setting. This suggests a potential anti-TIC effect of this combination and a role in overcoming endocrine resistance. Accrual to the expanded cohort is underway. If findings are confirmed, the second study with alternate MK-0752 dose/schedule may commence. Funding: Swim Across America, Inc. (clinical trial costs); Merck (drug supply, profiling)

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD05-12.

Esophagogastric junction adenocarcinoma according to Siewert classification in Taiwan

BACKGROUND

The incidence of adenocarcinoma of the esophagogastric junction (AEG) is rapidly increasing. We evaluated the clinicopathological difference and outcomes of Taiwanese patients with AEG according to the Siewert classification.

METHODS

Data were prospectively collected between December 1987 and July 2007. Two hundred thirty-one patients underwent curative resection of AEG at Taipei Veterans General Hospital and were divided into different Siewert types. The clinicopathological characteristics, operative morbidity, survival, and initial recurrence pattern were compared between the different types.

RESULTS

Fifty-one type II and 180 type III cancer patients were studied. Subtotal esophagectomy via a left thoracotomy (19.6% vs 2.8%), smaller tumor size (4.43 +/- 2.04 vs. 5.35 +/- 2.03 cm), and more combined organ resection (60% vs. 43.1%) were more common in type II than type III cancer. Multivariate analysis showed that three independent risk factors for death were gender, tumor size, and lymphovascular invasion. There were long-term survivors among the patients with lesser curvature site lymph node metastasis, whereas metastasis to the lymph nodes of the distal stomach and along the greater curvature site was associated with poor prognosis. The 5-year survival was similar between type II and type III cancer (59.6% vs. 63.5%, P = 0.947).

CONCLUSIONS

Lymphovascular invasion, tumor size, and gender were determined to be three independent factors of survival after curative resection for AEG, and Siewert type was not associated with differences in survival.

Mucin-producing gastric cancer: clinicopathological difference between signet ring cell carcinoma and mucinous carcinoma

BACKGROUND/AIMS

Signet ring cell carcinoma and mucinous carcinoma are mucin-producing gastric cancers. Their clinicopathological difference was obscure.

METHODOLOGY

From December 1987 to July 2005, a total of 1612 gastric cancer patients received curative surgery, 128 patients with signet ring cell carcinoma and 48 with mucinous carcinoma were enrolled in this study. Clinicopathological data were compared between the two groups.

RESULTS

Early stage (stage I and II) patients with mucinous carcinoma were associated with more male predominant (p = 0.002), larger tumor size (p = 0.020), deeper cancer invasion (p < 0.001), and a worse 5-year overall survival (63.6% vs 88.2%, p = 0.012) than those with signet ring cell carcinoma. There was no significant difference between the two groups with advanced stage in 5-year overall survival. There is no significant difference in the initial recurrence pattern between the two groups.

CONCLUSIONS

Patients with mucinous carcinoma had different biological behaviors with those with signet ring cell carcinoma, in particular early stage, hence had a worse survival.

Arachnoiditis ossificans

Arachnoiditis ossificans is a rare type of chronic arachnoiditis characterised by the presence of calcification or ossification of the spinal arachnoid. There are a few reports of this condition in Japanese and western populations but no case has been reported in a Chinese population before. We describe a 35-year-old woman with typical findings of arachnoiditis ossificans. A brief review of the literature is also presented.

Streptococcal mural endocarditis and myocardial abscess occurring in a left ventricular aneurysm--case report and review

Infection of the mural endocardium within a left ventricular aneurysm without valvular involvement is exceedingly rare. The presenting clinical features can be non-specific, and a high index of suspicion is required for its diagnosis. Delay in diagnosis invariably leads to a fatal outcome. Although no controlled studies are available to guide therapy and management of these patients, appropriate antibiotic therapy and early surgical resection of the infected ventricular aneurysm remain the cornerstone of therapy.

The conjoint junction of the triceps surae: Implications for gastrocnemius tendon lengthening

Forty embalmed cadaver lower limbs were dissected to identify the morphology of the conjoint junction of the tendons of gastrocnemius and soleus and the location of the gastrocnemius tendon relative to bony landmarks. Five patterns of conjoint junction morphology were found: transverse (25%), oblique passing distally and medially (45%), oblique passing distally and laterally (5%) and arcuate as an inverted U (17.5%) and a U-shape (7.5%). Left-right asymmetry of the junction was observed in 31.6% of 19 paired cadaver legs. On the medial side of the calf the gastrocnemius tendon could be located between 38 and 46% of the proportion of the distance between the upper border of the calcaneus and the fibular head. Corresponding values for the midline and lateral side of the calf were 45-58% and 48-51%. The location of the gastrocnemius tendon relative to bony landmarks may help to guide incision planning for open or endoscopic division of the tendon.

Stage migration influences on stage-specific survival comparison between D1 and D3 gastric cancer surgeries

AIMS

We evaluate the influency stage migration in a randomised trial comparing D1 (N 1 lymphadenectomy) and D3 (N 1, 2 and 3 lymphadenectomy) dissections.

METHODS

Two hundred and thirteen curatively resected patients were analysed, with this TNM data.

RESULTS

After applying D3 patients' data according to simulated D1 staging, D3 resections were associated with up-staging to N2-3 levels in 8% of patients according to the N stage. The likelihood of N-status migration increased with increasing depth of invasion into the gastric wall. The increases in the calculated survival rate after stage migration on known 5-year survival rates were: 2% in stage IB, 1% in stage II, 4% in stage IIIA, and 1% in stage IIIB.

CONCLUSIONS

Stage migration secondary to meticulous lymph node dissection affects stage-specific survival rates. True therapeutic survival benefit of D3 resection can only be assessed in this context.

Randomized clinical trial of morbidity after D1 and D3 surgery for gastric cancer

BACKGROUND

A randomized comparison of D1 (level 1 lymphadenectomy) and D3 (levels 1, 2 and 3 lymphadenectomy) dissection was performed to evaluate morbidity and effects on survival from gastric cancer.

METHODS

A total of 221 patients were studied after resection for gastric cancer, 110 after D1 surgery and 111 after D3 surgery.

RESULTS

The morbidity rate was higher after D3 than after D1 resection (17.1 (95 per cent confidence interval (c.i.) 10.1 to 24.1) versus 7.3 (95 per cent c.i. 2.4 to 12.2) per cent respectively; P = 0.012). The difference was largely related to abdominal abscess (8.1 per cent after D3 versus none after D1 resection; P = 0.003). The D3 group had an anastomotic leak rate of 4.5 per cent whereas there was no leakage in the D1 group (P = 0.060). All anastomotic leaks were minor and were managed non-operatively with nutritional support. Patients who had D3 resection had longer operating times, greater blood loss and postoperative drain outputs, and more patients needed blood transfusion. There was no death in either group. The hospital stay was longer after D3 than D1 surgery (mean(s.d.) 19.6(13.9) (range 10-98) versus 15.0(4.0) (range 10-30) days; P = 0.001).

CONCLUSION

Extended lymphadenectomy for gastric cancer is associated with more complications than limited lymphadectomy but this does not lead to significant mortality.

Does the extent of surgery have an impact on the survival of patients who receive postoperative radiation therapy for supratentorial low-grade gliomas?

We evaluate the impact of extent of surgery (EOS) on survival of patients with supratentorial nonpilocytic low-grade gliomas (LGG) treated with postoperative radiation therapy (PORT). Sixty-five patients with pathologically confirmed supratentorial nonpilocytic LGG (36 astrocytomas and 29 oligodendrogliomas) were treated with PORT after different extents of surgery: 12 gross total resections (GTR), 27 minimal or subtotal resections (MR/SR), and 26 biopsies (B). EOS was confirmed with postoperative imaging. The median radiation dose delivered was 5,940 cGy (range, 4,950-6,620 cGy). One of 12 patients (8%) in the GTR group and 12 of 53 patients (23%) in the less than GTR group demonstrated contrast enhancement. The median follow-up was 61 months (range 5-194 month). The 10-year overall survival (OS) was 82.5% and 32% for the GTR and the less than GTR groups, respectively (P = 0.0008). The corresponding 10-year disease-specific survival (DSS) was 90% and 41.4%%, respectively (P = 0.001). Multivariate analysis showed that only contrast enhancement and EOS were predictors for OS and DSS. Our data suggest that EOS correlates with OS and DSS in patients who have PORT. GTR should be the goal if technically achievable without causing significant morbidity, and its combination with PORT is compatible with long-term survival.

A genome-wide study of microsatellite instability in advanced gastric carcinoma

BACKGROUND

Microsatellite instability (MSI) has been described in many human carcinomas, including gastric carcinomas (GCs). There are inconsistent findings regarding the association of MSI with various subsets of GC with specific clinicopathologic features. The objective of this study was to define MSI in advanced GC at a genome-wide level and to evaluate the clinical relevance of MSI in these patients.

METHODS

Forty-one gastric adenocarcinomas with serosa invasion (T3) were analyzed at 59 loci that detected at least one site per arm of each autosome in human genome. The expression patterns of mismatch repair proteins hMLH1 and hMSH2 were examined by immunohistochemistry. Comparisons were made by categorizing tumors into three groups: tumors with MSI at multiple loci (at more than three loci), tumors with MSI at low level (at one to three loci), and microsatellite-stable (MSS) tumors. Clinical significance of MSI in advanced GC was evaluated. The relative rates of hypermutability of the 59 markers also were determined.

RESULTS

A significant association was found between tumors with MSI at multiple loci and the expanding type of tumor growth by Ming's histologic classification (P = 0.001), whereas tumors with MSI at low level and MSS tumors are clinicopathologically indistinguishable. The 59 dinucleotide repeat markers displayed varying degrees of susceptibility toward genetic instability. The relative rates of hypermutability of these markers were consistent with a normal distribution pattern in which the frequency of unstable tumors detected at different chromosomal loci varied from 0% to 20%.

CONCLUSIONS

The authors' results showed that advanced GC with MSI at multiple loci progress preferentially in an expanding mode, supporting the notion that high MSI tumors and low MSI/MSS tumors evolve through different genetic pathways. Thus, microsatellite testing may have clinical utility as a favorable prognostic marker.

A genome-wide study of microsatellite instability in advanced gastric carcinoma

BACKGROUND

Microsatellite instability (MSI) has been described in many human carcinomas, including gastric carcinomas (GCs). There are inconsistent findings regarding the association of MSI with various subsets of GC with specific clinicopathologic features. The objective of this study was to define MSI in advanced GC at a genome-wide level and to evaluate the clinical relevance of MSI in these patients.

METHODS

Forty-one gastric adenocarcinomas with serosa invasion (T3) were analyzed at 59 loci that detected at least one site per arm of each autosome in human genome. The expression patterns of mismatch repair proteins hMLH1 and hMSH2 were examined by immunohistochemistry. Comparisons were made by categorizing tumors into three groups: tumors with MSI at multiple loci (at more than three loci), tumors with MSI at low level (at one to three loci), and microsatellite-stable (MSS) tumors. Clinical significance of MSI in advanced GC was evaluated. The relative rates of hypermutability of the 59 markers also were determined.

RESULTS

A significant association was found between tumors with MSI at multiple loci and the expanding type of tumor growth by Ming's histologic classification (P = 0.001), whereas tumors with MSI at low level and MSS tumors are clinicopathologically indistinguishable. The 59 dinucleotide repeat markers displayed varying degrees of susceptibility toward genetic instability. The relative rates of hypermutability of these markers were consistent with a normal distribution pattern in which the frequency of unstable tumors detected at different chromosomal loci varied from 0% to 20%.

CONCLUSIONS

The authors' results showed that advanced GC with MSI at multiple loci progress preferentially in an expanding mode, supporting the notion that high MSI tumors and low MSI/MSS tumors evolve through different genetic pathways. Thus, microsatellite testing may have clinical utility as a favorable prognostic marker.

A genome-wide study of microsatellite instability in advanced gastric carcinoma

BACKGROUND

Microsatellite instability (MSI) has been described in many human carcinomas, including gastric carcinomas (GCs). There are inconsistent findings regarding the association of MSI with various subsets of GC with specific clinicopathologic features. The objective of this study was to define MSI in advanced GC at a genome-wide level and to evaluate the clinical relevance of MSI in these patients.

METHODS

Forty-one gastric adenocarcinomas with serosa invasion (T3) were analyzed at 59 loci that detected at least one site per arm of each autosome in human genome. The expression patterns of mismatch repair proteins hMLH1 and hMSH2 were examined by immunohistochemistry. Comparisons were made by categorizing tumors into three groups: tumors with MSI at multiple loci (at more than three loci), tumors with MSI at low level (at one to three loci), and microsatellite-stable (MSS) tumors. Clinical significance of MSI in advanced GC was evaluated. The relative rates of hypermutability of the 59 markers also were determined.

RESULTS

A significant association was found between tumors with MSI at multiple loci and the expanding type of tumor growth by Ming's histologic classification (P = 0.001), whereas tumors with MSI at low level and MSS tumors are clinicopathologically indistinguishable. The 59 dinucleotide repeat markers displayed varying degrees of susceptibility toward genetic instability. The relative rates of hypermutability of these markers were consistent with a normal distribution pattern in which the frequency of unstable tumors detected at different chromosomal loci varied from 0% to 20%.

CONCLUSIONS

The authors' results showed that advanced GC with MSI at multiple loci progress preferentially in an expanding mode, supporting the notion that high MSI tumors and low MSI/MSS tumors evolve through different genetic pathways. Thus, microsatellite testing may have clinical utility as a favorable prognostic marker.

Tie-1 tyrosine kinase is an independent prognostic indicator for invasive breast cancer

Receptor tyrosine kinases are known to be involved in the growth, progression and metastasis of solid tumors. We investigated the relationship between tie-1 expression and progression of invasive ductal breast carcinoma with immunohistochemical analysis. Tie-1 protein was detected in the microvessel endothelial cells and cytoplasm of tumor cells. The tumor size and stage were significantly associated with the expression of tie-1, which portends a worse 5-year disease-free status (39.3% v 59.2%, p = 0.07) and overall survival rate (67.3% v 93%, p = 0.02) than those without tie-1 expression. Multivariate analysis demonstrated that larger tumor size, presence of lymph node metastasis and tie-1 expression were independent prognostic parameters, both in 5-year disease-free survival and overall survival. Patients with lymph node metastases and tie-1 expression had the worst 5-year disease-free survival (0%) and overall survival (42.4%) compared to those without tie-1 expression (50.2%, 85%). In lymph node negative patients, those without tie-1 expression had better 5-year disease-free survival and overall survival (72.9%, 100%) compared to those with tie-1 expression (65.5%, 87.7%). We conclude that tie-1 expression is an independent prognostic factor for invasive ductal breast carcinoma, adversely affecting survival of breast cancer patients with positive nodes to a significant extent.

Comparison of the UICC/AJCC 1992 and 1997 pN categories for gastric cancer patients after surgery

BACKGROUND/AIMS

UICC/AJCC 1997 classification changes pN category. We evaluated its prognostic impact.

METHODOLOGY

A total of 710 patients who underwent a > or = D2 gastrectomy were recruited. Among them, the data of 319 patients who had involved regional lymph nodes and no evidence of distant metastases were used for comparing the 1992 and 1997 pN categories.

RESULTS

For 1997 category, 201 patients (64%) were pN1, 75 (23.5%) pN2, and 43 (13.5%) pN3. For 1992 category, 143 patients (44.8%) were pN1, and 147(46.1%) pN2. 29 patients (9.1%) with lymph node metastasis to the hepatoduodenal ligament were distant metastasis. The 1997 pN category was a more powerful prognostic discriminant (relative risk: 2.086) than the 1992 category. Compared to the 1992 stage classification, the 1997 one had a skewed distribution of patients with marked shift of patients of stage IIIA (105-126 patients), IIIB (116-58 patients), and IV (100-122 patients). The survival difference between stage IIIA and IIIB for the 1997 stage classification is narrower than for 1992.

CONCLUSIONS

The 1997 pN category allows for estimation of prognosis superior to the 1992 category.

Effects of acute hyperglycaemia on cardiac function: an echocardiographic study of monozygotic twins

BACKGROUND

A major cause of morbidity in type I diabetes is congestive heart failure due predominantly to left ventricular diastolic dysfunction. The mechanism of diastolic dysfunction remains unknown and does not relate to blood pressure, microvascular complications and glycated haemoglobin. Hyperglycaemia is the hallmark of diabetes and is a potential determinant of left ventricular diastolic dysfunction.

OBJECTIVE

To determine whether acute hyperglycaemia can induce changes in left ventricular diastolic function in normal subjects similar to those observed in insulin-dependent diabetes mellitus (IDDM).

DESIGN

Cross-sectional study.

SETTING

London teaching hospital.

SUBJECTS

Sixteen twins from eight identical twin pairs discordant for IDDM (age 18-38 years, five male) were studied; none had a history or evidence of myocardial ischaemia, valvular or primary heart muscle disease, systemic hypertension or nephropathy.

INTERVENTIONS

Non-diabetic twins underwent a hyperglycaemic clamp at 10 mmol/l.

MAIN OUTCOME MEASURES

Doppler echocardiography was performed in basal condition in identical twin pairs discordant for IDDM and repeated in the non-diabetic twins during hyperglycaemia. Blood glucose, insulin and catecholamines were measured at baseline and during hyperglycaemia.

RESULTS

Transmitral Doppler E/A velocity ratio was significantly lower in diabetic than non-diabetic twins at baseline (1.44 (0.38) vs. 1.51 (0.19), P<0.05). Glucose infusion in the non-diabetic twins resulted in an increase in their E/A ratio (1.51 (0.19) vs. 1.82 (0. 47), P<0.05) due to an increase in E velocity (68 (12) to 64.7 (10. 7), P<0.05) and a decrease in the peak A velocity (42.7 (3.85) to 38. 0 (4.1), P<0.05). No significant changes were observed in peak E velocity or isovolumic relaxation time in the non-diabetic twins between baseline and hyperglycaemia.

CONCLUSIONS

The alterations in left ventricular diastolic function induced by acute hyperglycaemia and consequent increase in plasma catecholamines do not mimic those demonstrated in IDDM patients.

Concomitant chemoradiation treatment in the management of patients with extrahepatic biliary tract recurrence of gastric carcinoma

BACKGROUND

The aim of this study was to determine the role of concomitant chemoradiation in the alleviation of obstructive jaundice in patients with extrahepatic biliary tract metastases from gastric carcinoma.

METHODS

Thirteen patients with good performance status who had obstructive jaundice resulting from extrahepatic biliary metastases after gastrectomy for gastric carcinoma were treated with palliative intent. Treatment consisted of insertion of a percutaneous transhepatic choledochal drainage (PTCD) catheter followed by external radiation up to a total dose of 40-60 grays in combination with chemotherapy (cisplatin 20 mg/m(2)/day, 5-fluorouracil 600 mg/m(2)/day, and leucovorin 90 mg/m(2)/day for 96 hours during the first and fifth weeks) on an outpatient basis.

RESULTS

The concomitant chemoradiation produced a good palliative effect in all 13 patients. Hyperbilirubinemia continued to improve after treatment, patients' clay-colored stool resolved within an average of 4 weeks (range, 2-6 weeks), and bilirubin levels returned to normal. The PTCD catheter could be removed after treatment was completed (the seventh week); the mean duration of PTCD placement was 2 months. The entire treatment course was performed on an outpatient basis; hospital admission was necessary only for PTCD insertion and chemotherapy. Ten patients died of their disease, with an average survival of 14.4 months (range, 4-31 months) from the time of PTCD insertion. Three patients are still alive at 16, 21, and 8 months. Biliary tract patency was maintained until death. No serious treatment-related complications occurred, and no endoprothesis or intraluminal brachytherapy was needed in this study.

CONCLUSIONS

Satisfactory palliation can be achieved by concomitant chemoradiation for patients with obstructive jaundice resulting from extrahepatic biliary metastases from gastric carcinoma, providing an alternative treatment choice for these patients.

Surgical mortality, survival, and quality of life after resection for gastric cancer in the elderly

Although there were some studies on clinicopathologic characteristics, operative morbidity, and mortality in elderly patients with gastric cancer, no reports have specifically focused on survival and quality of life after resection. A total of 433 patients aged >/= 65 years (1987-1994) who underwent gastric resection for gastric adenocarcinoma were studied. Two groups were considered: patients aged 65 to 74 years and those > 74 years. Most of the patients (78.1%) had advanced diseases, and nearly half (41. 3%) had associated chronic disease(s). Resections with curative intention were performed in 362 patients (83.6%). The overall operative morbidity rate was 21.7% and mortality rate 5.1%. Although operative procedures were similar in both groups, patients aged >74 years had a higher mortality rate than those aged 65 to 74 years (10. 1% vs. 3.5%; p = 0.034). Age and extent of gastric resection were two independent factors negatively affecting mortality. The cumulative survival rates for patients who underwent curative resection were 86.2%, 72.4%, 67.2%, 62.9%, and 60.0% at 1, 2, 3, 4, and 5 years, respectively. Nearly all patients (96%) after surgery had normal work and daily activities. Some patients appeared to lack energy (16%) or experienced a period of anxiety or depression. There was no statistical difference in survival and quality of life assessed by the Spitzer index after curative resection between the two groups. Therefore resection with curative intention can be performed for the elderly with acceptable morbidity and mortality rates, possible long-term survival, and good quality of life, but a limited operation should be considered in the very elderly patients.

Serum matrix metalloproteinase-9 level associated with stromal reaction in patients with gastric cancer

BACKGROUND

Matrix metalloproteinase 9 (MMP-9) plays an important role in cancer invasion and metastasis. The relationship between serum MMP-9 levels and clinicopathological factors in gastric cancer patients is not clear.

MATERIALS AND METHODS

Preoperative serum was obtained from 170 patients who had undergone gastrectomy for gastric cancer at the Veterans General Hospital-Taipei. The serum MMP-9 level was measured using a sandwich enzyme-linked immunoassay by monoclonal antibodies.

RESULTS

The median serum MMP-9 level was 368.6 ng/mL (range: 43.9-1871.3 ng/mL). Univariate analysis showed that stromal reaction and Lauren's histological classification were two factors related to serum MMP-9 levels (p = 0.014 and p = 0.030 respectively). Multivariate analysis revealed that stromal reaction was the only factor independently (odds ratio: 1.695) associated with MMP-9 levels. Patients with a serum MMP-9 level < 368.5 ng/mL had a tendency towards better survival rate (5-year survival rate: 64.4%) than those with > 368.5 ng/mL (58.5%), but this tendency did not reach statistical significance (p = 0.512).

CONCLUSION

These data suggests that serum MMP-9 levels are associated with stromal reaction in gastric cancer.

Role of serial tumor markers in the surveillance for recurrence in endometrial cancer

The aim of this study is to evaluate the usefulness of tumor markers in the follow-up of patients with endometrial cancer. The sera of 23 patients with elevated pretreatment CA125, CA15.3, and CA19.9 were collected at each follow-up visit and analyzed. Eleven patients had normal posttreatment levels and none of them developed recurrence. Twelve patients had one or more increased tumor markers, 7 (58.3%) of them developed recurrence. Among these seven patients, six had CA125 elevated by at least 10-fold and one had elevated CA19.9. The median lead time between elevation of tumor markers and clinical evidence of recurrence was 6 months. Hence posttreatment elevation of CA125 is a useful predictor for recurrence in patients with elevated pretreatment levels.

Negative captopril renography on patients with renin mediated hypertension due to page kidney and reninoma

Through a mechanism similar to renal artery stenosis, patients with reninoma and page kidney also suffered from renin mediated hypertension. Captopril renograms performed on our patients with the latter two conditions, however, did not yield diagnostic findings. Therefore, equivocal or negative captopril renography cannot serve to rule out conditions with elevated renin other than renal artery stenosis.

Poorer prognosis in young patients with gastric cancer?

BACKGROUND/AIMS

Although the relationship between prognosis and age of patients with gastric cancer is controversial, a poorer prognosis in young patients has been suggested by most investigators. To further examine the hypothesis, a retrospective study was undertaken to analyze a large series of patients with gastric cancer in Taiwan.

METHODOLOGY

A total of 1,642 consecutive patients diagnosed with gastric cancer and receiving further management at one medical center from 1988 to 1993 were reviewed. The gender, TNM tumor stage, rate of curative resection and survival of the patients were compared in the young age group (< or = 39 years) and the old age group (> 39 years). Survival was estimated with the product-limit method and difference in survival was tested by the log-rank test. Multivariate analysis was done by the Cox proportional hazard model.

RESULTS

Among the 1,642 patients, 61 patients were in the young age group and 1,581 patients were in the old age group. There was no significant difference for the 2 groups of patients in the distribution of TNM stage (stage I: 20%; II: 8%; III: 13%; IV: 59% vs. 19%, 11%, 25% and 45% respectively, in the old age group, p = 0.098) and rate of curative resection (38% vs 51% in the old age group, p = 0.059). The overall 5-year survival showed no significant difference between the 2 groups (25% vs. 29% in the old). Subgroup analyses showed that survival after curative resection and survival without curative treatment (including palliative resection and no resection) also had no difference in the 2 groups. Multivariate analysis also showed that age was not an independent factor.

CONCLUSIONS

Although most reports suggested a dismal prognosis in young patients with gastric cancer, based on our findings, young patients (< or = 39 years) do not have a worse prognosis than older patients.

Inhibition of focal contact formation in cells transformed by p185neu

Signaling pathways mediated by adhesive molecules are tightly associated with cytoskeletal organization and cell growth regulation. Focal adhesion kinase (FAK) plays a prominent role in the adhesion signaling pathway through its tyrosine kinase activity and protein-protein interaction with other signaling molecules, including src, paxillin, and p130CAS, and other proteins. We explored the roles of these signaling molecules in the transformation of B104-1-1 cells, an NIH/3T3-derived cell line transformed by activated rat p185neu. The cytoskeletal organization of the p185neu-transformed cells was disrupted, and their morphology was dramatically altered. FAK, paxillin, and p130CAS appeared to be tyrosine phosphorylated in both NIH/3T3 and B104-1-1. However, the phosphorylation levels of paxillin and p130CAS were lower in B104-1-1 cells than in NIH/3T3 cells. Surprisingly, the association between FAK and paxillin was enhanced in B104-1-1 cells, suggesting reorganization of protein-protein interaction modulated by protein phosphorylation. Our results showed that even though cellular transformation by src and neu has similar consequences, such as focal adhesion disassembly and increased metastasis potential, the molecular events underlying the signaling pathways can be dramatically different.

[Vancomycin-resistant enterococci in north-eastern Taiwan]

Vancomycin-resistant enterococci (VRE) is a world-wide emerging pathogen. The first confirmed VRE isolate in Taiwan was detected in 1995. After that, more and more isolates of VRE were found in western part of Taiwan. However, before this report, there was no any isolate of VRE found in eastern part of Taiwan. In December 1997 and January 1998, two cases of VRE urinary tract infection were found in two regional hospitals in north-eastern Taiwan. They had received prolonged treatment with multiple antibiotics for other infections before they got VRE infection. The isolates showed susceptibility to other antimicrobial agents by routine disk diffusion susceptibility test and these two patients were successfully treated. The VRE did not spread in those two hospitals. After further study, the 3 isolates from these two patients all had minimum inhibitory concentration of vancomycin >256 microg/mL. They all carried van A gene and the pulsed-field gel electrophoresis demonstrated they belonged to different DNA types. It was concluded that VRE appeared in north-eastern Taiwan but the strains were not from a common source.

Factors correlated with number of metastatic lymph nodes in gastric cancer

OBJECTIVE

We had previously reported a reasonable categorization of the number of positive lymph nodes (LN: 0, 1-4, 5-8, and > 8) as a prognostic indicator. This study was an extension, to see which factors correlated with number of positive lymph nodes.

METHODS

A total of 533 patients with gastric adenocarcinoma, who underwent curative surgery between January 1988 and December 1995, were entered into this study. Patients were divided into four groups according to metastatic LN number (0, 1-4, 5-8, and > 8). Their survival and clinicopathological factors were analyzed.

RESULTS

A total of 16,457 LNs, with an average of 30.9 per specimen, were removed, of which 1686 (10.2%) showed metastases. The 5-yr cumulative survival rate decreased as the number of metastatic LNs increased, ie., 91.3% for LN 0; 67.4% for LN 1-4; 37.2 for LN 5-8, and 14.1% for LN > 8. Multivariate analyses showed that depth of cancer invasion (odds ratio: 2.4), gross appearance (odds ratio: 1.9), size (odds ratio: 1.9), and location (odds ratio: 1.4) of tumor were four independent factors correlated with the number of metastatic LNs. Number of metastatic LNs increased with advanced Japanese nodal stage and UICC-TNM stage.

CONCLUSIONS

Depth of tumor invasion, and gross appearance, size, and location of tumor were four pathological factors independently correlated with number of metastatic LNs in gastric cancer.

Multiple symmetric lipomatosis in the Chinese: ultrasound, CT and MR imaging

We report four cases of multiple symmetric lipomatosis in the Chinese population. We believe that multiple symmetric lipomatosis in the Chinese is not uncommon and may be related to the increasing incidence of alcoholism. The ultrasound appearances of these lipomatous masses are presented for the first time. Heterogeneous echogenic masses with fine fibrous strands that insinuate around fascial planes, lymph nodes and vascular tissues are typical findings. Unlike diseases affecting the Western population, multiple symmetric lipomatosis in the Chinese appears to be limited to the head and neck.

Colonic diverticulosis in Hong Kong: distribution pattern and clinical significance

This is a retrospective study on the prevalence of diverticulosis in Hong Kong Chinese adults. Eight-hundred and fifty-eight consecutive barium enema examinations over a period of 18 months (January 1995-June 1996) were analysed. Results show that the prevalence of diverticulosis in our community is 25.1% with no significant difference between male and female adults. The prevalence is lower than Western countries but higher than in Asia. Moreover, the peak prevalence is at the 50-79 years age group with lower prevalence in the older age groups. This may be explained by the rapid rise in prevalence in the younger age groups so that the age-related increase in prevalence become obscured. We postulate that this may be due to Western cultural influence in our diet and lifestyle. There is no significant difference in the symptomatology of patients with and without diverticulosis, supporting the idea that diverticulosis alone is usually asymptomatic. There is predominance of right hemicolon involvement in our subjects, in contrast to the left hemicolon predominance in the Caucasian population. Of patients with diverticulosis, 55.3% have only right-sided involvement and 32.6% have bilateral involvement. Only 12.1% of patients with diverticulosis have exclusively left hemicolon involvement. Caecal and ascending colon diverticula are found in 6.4% and 17.6% of all the adults under study, respectively. Clinicians caring for patients from our community should take note of this high frequency of caecal and ascending colon diverticulosis as caecal and ascending colon diverticulitis is notoriously difficult to diagnose clinically.

Serum progesterone levels in patients with gastric adenocarcinoma before and after gastrectomy

BACKGROUND

Having observed that progesterone receptors exist in all gastric carcinoma tissues, the authors determined that serum progesterone levels in gastric carcinoma patients were worthy of evaluation.

METHODS

Serum progesterone levels were determined in patients with gastric adenocarcinoma and in patients with benign disease who served as controls. All female patients were older than 55 years. The clinicopathologic significance of their serum progesterone levels was determined.

RESULTS

In male patients (n = 122), the serum progesterone level (mean +/- standard deviation) was significantly higher than in the male control group (n = 163) (0.264+/-0.261 vs. 0.142+/-0.113 ng/mL; P < 0.001) and showed a tendency to be stage-related (P = 0.029). Serum progesterone levels significantly decreased after gastrectomy in patients with disease at Stage I (n = 27), II (n = 20), and III (n = 32), but not IV (n = 7). In 11 patients who died of recurrence, the serum progesterone levels were decreased when they were disease free but raised when recurrence was clinically evident. Patients with serum progesterone levels > 0.264 ng/mL survived for significantly shorter periods than those with levels < or = 0.264 ng/mL (P = 0.039). However, serum progesterone level was not an independent predictor of survival. Among the female patients (n = 12), the serum progesterone level (mean +/- standard deviation) of patients with gastric carcinoma was 0.427+/-0.428 ng/mL, whereas that of the control group (n = 17) was 0.217+/-0.451 ng/mL; the difference was statistically significant (P = 0.02). In female disease free patients studied postoperatively, the progesterone after gastrectomy showed a tendency to decrease, but this difference was not statistically significant (0.444+/-0.368 vs. 0.175+/-0.150 ng/mL; P = 0.091; n = 7).

CONCLUSIONS

These data suggest that serum progesterone level reflects the presence or absence of gastric carcinoma by some unknown mechanism.

Weekly etoposide, epirubicin, cisplatin, 5-fluorouracil and leucovorin: an effective chemotherapy in advanced gastric cancer

In order to optimize the therapeutic index of combining etoposide, epirubicin, cisplatin, 5-fluorouracil (5-FU), leucovorin (EEPFL) chemotherapy in the treatment of advanced gastric cancer, a trial of a novel schedule of weekly administration was conducted. Weekly EEPFL treatment consisted of a concomitant boost of etoposide 40 mg m(-2) i.v. over 30 min, epirubicin 10 mg m(-2) i.v. over 5 min to a backbone regimen, weekly PFL chemotherapy with cisplatin 25 mg m(-2), 5-FU 2200 mg m(-2), leucovorin 120 mg m(-2) given simultaneously by 24-h i.v. infusion. Response, survival and toxicity were evaluated. Forty-two patients were studied. Median age was 69 (range 31-84) years. Twenty-six per cent of patients showed complete response and 45% partial response. The overall response rate was 71% (95% confidence interval 58-84%). For a total of 507 weekly EEPFL cycles delivered, the incidence of grade 4 leucopenia was 1% of cycles. One patient died of neutropenia septicaemia. There was no other grade 4 toxicity. Grade 3 and 2 leucopenia occurred in 7% and 14% of cycles. The incidence of grade 3 and 2 mucositis was 1% and 3% of cycles. Grade 3 and 2 diarrhoea occurred in 0.4% and 1.6% of cycles. Overall median survival was 10 months (range 3-41+ months). Weekly EEPFL chemotherapy is an effective regimen with tolerable toxicities in the treatment of advanced gastric cancer. A randomized controlled clinical trial to formally assess the efficacy and benefit of EEPFL chemotherapy is under way.