Outcomes of Alprostadil as an Adjuvant Therapy with Indirect Angiosomal Revascularization in Patients with Critical Limb Ischemia after Failure of Direct Revascularization

OBJECTIVES

this study was carried out to assess the effectiveness of Alprostadil (Prostaglandin E1) when used as an adjuvant therapy with indirect revascularization in patients with critical limb ischemia after the failure of direct revascularization.

PATIENTS AND METHODS

At our centers, 120 patients suffering from infrainguinal peripheral arterial disease with critical limb ischemia underwent a failed trial of direct revascularization procedure, all revascularization procedures were endovascular. Median follow-up was two years and 2.5 years for patients with and without DM. In the Alprostadil group mean age was 63.41±12.52; 36 (60%) for males and 24 (40%) for females. Post-endovascular intervention Alprostadil was administrated immediately postoperatively by intravenous infusion of 40μg Alprostadil diluted in 100 ml of normal saline, over 2 hours every 12 hours for six days.

RESULTS

In Alprostadil group, the mean ± SD of the baseline ABI was 0.45±0.175, while the Mean ± SD of ABI at the end of our study was 0.65±0.216 with a difference from the baseline of 0.2±0.041 (P-Value = 0.08, <0.05 meaning that it is significant). Our 1-month primary patency rate was 93.3%, while our 3 and 6-month patency rate was 92.9%. In the control group, the mean ± SD of the baseline ABI was 0.68±0.22, while the Mean ± SD of ABI at the end of our study was 0.69±0.23 with a difference from the baseline of 0.01±0.01 (P-Value > 0.05 meaning that it is non-significant) 1-month patency rate was 89%, while 3-month and 6-month patency rate was 75%. When we compared the patient's leg vessels before and after our intervention, we found that the percentage of the no-runoff-vessels group decreased from 10 (16.7%) to 4 (6.67%). One-runoff-vessel group percentage dropped from 40 (66.7%) to 36 (60%), whereas, in the two-runoff-vessel group, the percentage increased from 10 (16.7%) to 20 (33.3%). We evaluate leg arteries; we do no pedal arch intervention. in the Alpostradil group. Out of the total of 60 patients, limb salvage occurred in 58 (96.7%) patients, and 2 (3.3%) patients underwent below-the-knee amputation (BKA) before the study ended.

CONCLUSION

Our results show the efficacy and safety of Alprostadil as an adjuvant therapy with indirect angiosomal revascularization in patients with tissue loss due to critical limb ischemia.

Identifying patients suitable for targeted adjuvant therapy: advances in the field of developing biomarkers for tumor recurrence following irradiation

Introduction

Radiation therapy (RT) is commonly used to treat cancer in conjunction with chemotherapy, immunotherapy, and targeted therapies. Despite the effectiveness of RT, tumor recurrence due to treatment resistance still lead to treatment failure. RT-specific biomarkers are currently lacking and remain challenging to investigate with existing data since, for many common malignancies, standard of care (SOC) paradigms involve the administration of RT in conjunction with other agents.

Areas Covered

Established clinically relevant biomarkers are used in surveillance, as prognostic indicators, and sometimes for treatment planning; however, the inability to intercept early recurrence or predict upfront resistance to treatment remains a significant challenge that limits the selection of patients for adjuvant therapy. We discuss attempts at intercepting early failure. We examine biomarkers that have made it into the clinic where they are used for treatment monitoring and management alteration, and novel biomarkers that lead the field with targeted adjuvant therapy seeking to harness these.

Expert Opinion

Given the growth of data correlating interventions with omic analysis toward identifying biomarkers of radiation resistance, more robust markers of recurrence that link to biology will increasingly be leveraged toward targeted adjuvant therapy to make a successful transition to the clinic in the coming years.

Prognostic Factors and Treatment Impact on Overall Survival in Adult Craniopharyngioma

OBJECTIVE

To examine the demographics, tumor characteristics, treatments, and clinical outcomes of a large adult craniopharyngioma population.

METHODS

The 2004-2018 National Cancer Database was queried to investigate adult patients with craniopharyngioma. Univariable and multivariable Cox hazard ratio analysis was conducted to analyze the overall survival (OS) impact of demographic and clinical variables.

RESULTS

A total of 666 adult patients with craniopharyngioma were identified with a mean age of 51 years (standard deviation 16 years). On multivariable analysis, independent of demographic and clinical variables, increased age, uninsured status, Medicaid, Medicare, Charlson-Deyo Comorbidity Index of 2, and tumor size greater than 40 mm were independently associated with worse OS. There was no significant difference in survival between histologic subtypes. Gross total resection (GTR) (hazard ratio [HR] 0.602, 95% confidence interval [CI] 0.384-0.942, P = 0.026) and subtotal resection (STR) with adjuvant radiotherapy (HR 0.316, 95% CI 0.140-0.710, P = 0.005) were independently associated with improved OS. GTR with radiotherapy trended towards improved OS (HR 0.601, 95% CI 0.334-1.083, P =0.090), but STR alone and radiotherapy alone demonstrated no significant difference in survival compared with no treatment on multivariable analysis. Kaplan-Meier survival models demonstrated improved survival with GTR, GTR + radiation therapy, and STR + radiation therapy. Patients undergoing endoscopic resection had significantly lower GTR rates and greater rates of adjuvant radiotherapy compared with open approaches but no difference in OS.

CONCLUSION

Adult patients with craniopharyngioma who underwent GTR or STR with adjuvant radiotherapy had significantly improved overall survival. Endoscopic approaches had lower rates of GTR but no difference in OS.

Impact of adjuvant chemotherapy on the overall survival of patients with resectable bulky small cell neuroendocrine cervical cancer: a JSGO-JSOG joint study

OBJECTIVE

The aim of this study was to review the clinicopathological characteristics of small cell neuroendocrine cervical cancer (SCNEC) and to identify the optimal treatment.

METHODS

The Japanese Society of Gynecologic Oncology conducted a retrospective cohort study of SCNECs enrolled in the Gynecological Tumor Registry of the Japan Society of Obstetrics and Gynecology between 2004 and 2015. All cases were modified and unified by International Federation of Gynecology and Obstetrics 2008 (Union for International Cancer Control 7th edition).

RESULTS

There were 822 registered patients diagnosed with SCNEC from 2004 to 2015 which comprised 1.1% (822/73,698) of all uterine cervical cancer cases. Rates of lymph-node and distant metastasis were significantly higher in T1b2 (38.9% and 13.7%, respectively) than T1b1 (14.2% and 4.4%, respectively) (p<0.01). In IB2 and T1bN1M0 SCNEC, the 5-year survival rate with surgery followed by chemotherapy was significantly higher than that with surgery followed by radiation therapy/concurrent chemoradiation therapy (p<0.01).

CONCLUSION

SNCEC tumors >4 cm in size had greater rates of lymph-node and distant metastasis when compared with tumors ≤4 cm. Adjuvant chemotherapy, rather than radiotherapy, may improve prognosis after surgery in T1bN1M0 SCNEC.

Adjuvant therapy with tyrosine kinase inhibitors for localized and locally advanced renal cell carcinoma: an updated systematic review and meta-analysis

PURPOSE

Tyrosine kinase inhibitors (TKIs) have been widely used in the management of patients with metastatic renal cell carcinoma (RCC). However, the use of systemic therapies in the adjuvant setting of localized and locally advanced RCC has shown conflicting results across the literature. Therefore, we aimed to conduct an updated systematic review and meta-analysis comparing the efficacy and safety of TKIs in the adjuvant setting for patients with localized and locally advanced RCC.

MATERIALS AND METHODS

The MEDLINE and EMBASE databases were searched in December 2020 to identify phase III randomized controlled trials of patients receiving adjuvant therapies with TKI for RCC. Disease-free survival (DFS) and overall survival (OS) were the primary endpoints. The secondary endpoints included treatment-related adverse events (TRAEs) of high and any grade.

RESULTS

Five trials (S-TRAC, ASSURE, PROTECT, ATLAS, and SORCE) were included in our meta-analysis comprising 6,531 patients. The forest plot revealed that TKI therapy was associated with a significantly longer DFS compared to placebo (pooled HR: 0.88, 95% CI: 0.81-0.96, P= 0.004). The Cochrane's Q test (P = 0.51) and I2 test (I2 = 0%) revealed no significant heterogeneity. Adjuvant TKI was not associated with improved OS compared to placebo (pooled HR: 0.93, 95% CI: 0.83-1.04, P= 0.23). The Cochrane's Q test (P = 0.74) and I2 test (I2 = 0%) revealed no significant heterogeneity. The forest plot revealed that TKI therapy, compared to placebo, was associated with higher rates of high grade TRAEs (OR: 5.20, 95% CI: 4.10-6.59, P< 0.00001) as well as any grade TRAEs (OR: 3.85, 95% CI: 1.22-12.17, P= 0.02). The Cochrane's Q tests (P < 0.0001 and P < 0.00001, respectively) and I2 tests (I2 = 79% and I2 = 90%, respectively) revealed significant heterogeneity.

CONCLUSIONS

The findings of our analyses suggest an improved DFS in patients with localized and locally advanced RCC receiving adjuvant TKI as compared to placebo; however, this did not translate into any significant OS benefit. Additionally, TKI therapy led to significant toxicity. Adjuvant TKI does not seem to offer a satisfactory risk and/orbenefit balance for all patients. Select patients with very poor prognosis may be considered in a shared decision-making process with the patient. With the successful arrival of immune-based therapies in RCC, these may allow a more favorable risk/benefit profile.

Novel therapies in the management of oral cancer: An update

An estimated 4% of all cancers are of the oral cavity or oropharyngeal. Presently, management of the oral cancers mainly includes surgery, radiotherapy, and chemotherapy either alone or in combination depending on the individual case. Each of these techniques has their advantages and disadvantages. Surgery demands removal of cancerous tissue causing disfigurement and functional impairment. Radiotherapy has significant side effects like mucositis, myelosuppression, xerostomia and dental caries. With the advent of newer treatment methods like the targeted therapy, immune therapy and gene therapy, treatment outcomes are better with fewer side effects. This has generally improved survival rates and quality of life of cancer patients.

Major clinical research advances in gynecologic cancer in 2019

In 2019, 12 topics were selected as the major research advances in gynecologic oncology. Herein, we first opted to introduce the significant clinical activity of pembrolizumab in women with advanced cervical cancer based on the results of the phase 2 KEYNOTE-158 trial. Thereafter, we reviewed 5 topics, including systemic lymphadenectomy in the advanced stage with no gross residual tumor, secondary cytoreductive surgery in recurrent ovarian cancer according to the results of Gynecologic Oncology Group-213 trial, dose-dense weekly paclitaxel scheduling as first-line chemotherapy, the utility of intraperitoneal therapy in the advanced stage, and an update on poly(ADP-ribose) polymerase (PARP) inhibitors for the treatment of ovarian cancer. Additionally, we conducted a thorough review of emerging data from several clinical trials on PARP inhibitors according to drug, target population, and combined usage. For uterine corpus cancer, we reviewed adjuvant therapy for high-risk disease and chemotherapy in advanced/recurrent disease. For the field of radiation oncology, we discussed the utility of neoadjuvant chemotherapy added to chemoradiotherapy and the treatment of radiation-induced cystitis using hyperbaric oxygen. Finally, we discussed the use of individualized therapy with humanized monoclonal antibodies (trastuzumab emtansine and sacituzumab govitecan-hziy) and combination therapy (fulvestrant plus alpesilib, fulvestrant plus anastrozole, and ribociclib plus endocrine therapy) for women with advanced breast cancer.

Effectiveness of trastuzumab as adjuvant therapy in patients with early stage breast cancer: A systematic review and meta-analysis

Background: Trastuzumab in combination with chemotherapy has long been established as a standard treatment for HER2-positive patients in early stage breast cancer (BC). The present study aimed at assessing the effectiveness of trastuzumab adjuvant therapy in early stage BC in overall survival (OS) and disease-free survival (DFS). Methods: A systematic review and meta-analysis was performed to evaluate the effectiveness of trastuzumab adjuvant therapy. PubMed, Cochrane library, Scopus, Web of Science, and Embase databases were searched for relevant RCTs from the beginning to February 2017. Quality assessment of studies was conducted using the Cochrane Risk of Bias Tool. The desired outcomes were OS and DFS. Results: A total of 1818 articles were identified first, however, only 11 studies were eligible to be included in this study. Our findings and meta-analysis results revealed that trastuzumab is effective in increasing OS (OS hazard ratio: -0.286 ± 0.049, 95%CI (-0.381, - 0.191)) and improving DFS (DFS hazard ratio: -0.419± 0.077, 95%CI (-0.569, -0.269)). The most serious but negligible side effect of trastuzumab is congestive heart failure. Conclusion: Adding trastuzumab as adjuvant therapy in early stages of BC in HER2 positive patients could increase OS and DFS of the patients effectively.

De-intensification of adjuvant therapy in human papillomavirus-associated oropharyngeal cancer

Current adjuvant treatment guidelines for oropharyngeal squamous cell carcinoma treated with primary surgery are based on studies that predate the human papillomavirus (HPV) era. HPV-associated oropharynx carcinoma (HPV-OPC) has a much more favorable prognosis compared to HPV-unassociated cancer and is increasingly considered to be a distinct disease entity due to its unique etiology, presentation, and behavior. Currently, there is significant interest in adjuvant treatment de-intensification of HPV-OPC patients in order to reduce treatment-related toxicity while maintaining excellent clinical outcomes. Here, we review the evidence and rationale underlying the ongoing prospective trials of adjuvant treatment de-intensification for HPV-OPC patients.

Practice patterns of adjuvant therapy for intermediate/high recurrence risk cervical cancer patients in Japan

Objective

Although radiation therapy (RT) and concurrent chemoradiotherapy (CCRT) are the global standards for adjuvant therapy treatment in cervical cancer, many Japanese institutions choose chemotherapy (CT) because of the low frequency of irreversible adverse events. In this study, we aimed to clarify the trends of adjuvant therapy for intermediate/high-risk cervical cancer after radical surgery in Japan.

Methods

A questionnaire survey was conducted by the Japanese Gynecologic Oncology Group to 186 authorized institutions active in the treatment of gynecologic cancer.

Results

Responses were obtained from 129 facilities. Adjuvant RT/CCRT and intensity-modulated RT were performed in 98 (76%) and 23 (18%) institutions, respectively. On the other hand, CT was chosen as an alternative in 93 institutions (72%). The most common regimen of CT, which was used in 66 institutions (51%), was a combination of cisplatin/carboplatin with paclitaxel. CT was considered an appropriate alternative option to RT/CCRT in patients with risk factors such as bulky tumors, lymph node metastasis, lymphovascular invasion, parametrial invasion, and stromal invasion. The risk of severe adverse events was considered to be lower for CT than for RT/CCRT in 109 institutions (84%).

Conclusion

This survey revealed a variety of policies regarding adjuvant therapy among institutions. A clinical study to assess the efficacy or non-inferiority of adjuvant CT is warranted.

Administration of Gemcitabine After Pancreatic Tumor Resection in Mice Induces an Antitumor Immune Response Mediated by Natural Killer Cells

BACKGROUND & AIMS

Even after potentially curative R0 resection, patients with pancreatic ductal adenocarcinoma (PDAC) have a poor prognosis owing to high rates of local recurrence and metastasis to distant organs. However, we have no suitable transgenic animal models for surgical interventions.

METHODS

To induce formation of pancreatic tumor foci, we electroporated oncogenic plasmids into pancreata of LSL-KrasG12D × p53fl/fl mice; mutant Kras was expressed in p53fl/fl mice using a sleeping beauty transposon. We co-delivered a transposon encoding a constitutively active form of Akt2 (myrAkt2). Carcinogenesis and histopathologic features of tumors were examined. Metastasis was monitored by bioluminescence imaging. Tumors were resected and mice were given gemcitabine, and tumor recurrence patterns and survival were determined. Immune cells were collected from resection sites and analyzed by flow cytometry and in depletion experiments.

RESULTS

After electroporation of oncogenic plasmids, mice developed a single pancreatic tumor nodule with histopathologic features of human PDAC. Pancreatic tumors that expressed myrAkt2 infiltrated the surrounding pancreatic tissue and neurons and became widely metastatic, reflecting the aggressive clinical features of PDAC in patients. Despite early tumor resection, mice died from locally recurring and distant tumors, but adjuvant administration of gemcitabine after tumor resection prolonged survival. In mice given adjuvant gemcitabine or vehicle, gemcitabine significantly inhibited local recurrence of tumors, but not metastasis to distant organs, similar to observations in clinical trials. Gemcitabine inhibited accumulation of CD11b+Gr1intF4/80int myeloid-derived suppressor cells at the resection margin and increased the number of natural killer (NK) cells at this location. NK cells but not T cells were required for gemcitabine-mediated antitumor responses.

CONCLUSIONS

Gemcitabine administration after resection of pancreatic tumors in mice activates NK cell-mediated antitumor responses and inhibits local recurrence of tumors, consistent with observations from patients with PDAC. Transgenic mice with resectable pancreatic tumors might be promising tools to study adjuvant therapy strategies for patients.

Pretreatment predictors of adjuvant chemoradiation in patients receiving transoral robotic surgery for squamous cell carcinoma of the oropharynx: a case control study

Background

The purpose of this study was to identify preoperative patient characteristics associated with the incidence of positive surgical margins or lymph node extracapsular extension (ECE), which necessitate adjuvant chemoradiation after transoral robotic surgery (TORS).

Methods

We conducted a single institution retrospective study of 34 consecutive patients with primary oropharyngeal cancer who underwent TORS. All imaging was reviewed by a single neuroradiologist. Surgical margins and ECE status were determined by a single head and neck pathologist. Associations of preoperative patient characteristics with positive surgical margins and lymph node ECE were examined using univariate analysis. Independent predictors of these outcomes were determined using logistic regression.

Results

Preoperatively, the majority of patients had early-stage disease (7 cT1 and 21 cT2; 10 cN0). Positive margins occurred in 4 (12 %) patients. A clinically positive lymph node was seen in 23 (68 %) patients. Neck dissection was performed in 29 (85 %) patients, among whom 19 had a pathologically positive lymph node and 15 had nodal ECE. Logistic regression showed that larger preoperative lymph node size was an independent predictor of ECE (odds ratio, 13.32 [95 % CI, 1.46–121.43]). Among the 21 patients with a clinically positive lymph node who underwent neck dissection, ECE was present more often in patients with a preoperative node size ≥ 3.0 vs. < 3.0 cm (92 % vs. 44 %, P = 0.046). There was no patient characteristic associated with positive margins.

Conclusions

Patients with a larger preoperative lymph node appear more likely to have ECE, and thus be treated with chemoradiation after TORS, with a potentially higher rate of toxicity. Lymph node size should be taken into account when deciding upon treatment approaches. Further research is needed to validate these results.

Electronic supplementary material

The online version of this article (doi:10.1186/s41199-016-0008-7) contains supplementary material, which is available to authorized users.

[Standard therapy of tuberculosis]

Based on the results of studies from the 1960s-1980s the current four drug combination therapy was established as standard or short course tuberculosis therapy worldwide. The regional epidemiology and the often unique conditions within a national health system create the need for specific adjustments. Over the last years these were realized by the German central committee against tuberculosis (DZK) in the recommendations for tuberculosis therapy. Because of the recent development of migration into Germany from countries with higher tuberculosis incidences an increase in tuberculosis cases is to be expected. The expected increase in tuberculosis cases will lead to more contact with tuberculosis patients even in the outpatient setting. New S2k guidelines guided by the Association of the Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF) for the treatment of tuberculosis for children and adults are under development. Before the release of the comprehensive guidelines, practical evidence for the diagnosis and treatment of uncomplicated tuberculosis is summarized in this document to meet the challenges of the recent developments.

Controversies in the management of endometrial cancer: a survey of the Korean Gynecologic Oncology Group

Objective

To identify current practice patterns for unresolved issues in the surgical and adjuvant management of endometrial cancer in Korea.

Methods

We designed and conducted a survey of all 218 active members of the Korean Gynecologic Oncology Group to try to identify how they would manage various case scenarios for endometrial cancer. Data were collected using an Internet survey database.

Results

A total of 108 members (49.5%) responded to the survey. Laparoscopy (81.6%) was the most commonly used mode of surgery in early-stage endometrial cancer. Of all the respondents, 19.8% stated that lymphadenectomy could be omitted and 21.7% recommended selective lymphadenectomy based on sentinel biopsy or frozen results for patients with presumed stage IA/grade 1 disease. On the other hand, 71.9% of respondents recommended para-aortic lymphadenectomy for patients with presumed stage IB/grade 1 disease and 86.4% recommended this treatment for presumed stage IB/grade 3 disease. The majority of respondents performed adjuvant therapy for stage IB/grade 2 (91.7%), IB/grade 3 (99.0%), and stage II (89.6%). Whole pelvic radiotherapy and vaginal brachytherapy were the most frequently used options among these patients. All respondents administered adjuvant therapy when node metastasis was found, and concurrent chemoradiotherapy (53.2%) was the most preferred option for stage IIIC1 disease.

Conclusion

There is broad variation in both the surgical and adjuvant treatment of endometrial cancer among Korean gynecologic oncologists.

Male breast cancer: 20-year survival data for post-mastectomy radiotherapy

BACKGROUND

The goal of this population-based study was to determine the impact of post-mastectomy radiation therapy on long-term overall survival (OS) of male patients with breast cancer.

PATIENTS AND METHODS

We investigated 20-year OS rates of 664 patients diagnosed with primary stage I-III breast cancer in former East Germany between 1970 and 1989. Patients had a radical mastectomy with axillary lymph node dissection without systemic adjuvant therapy.

RESULTS

Median follow-up time was 26.2 years (range 19-38 years). 52.4% of the patients had post-mastectomy radiotherapy. Radiotherapy showed different effects in each stage group after 20 years. Whereas there was an OS trend for radiotherapy to harm patients with stage I disease (hazard ratio (HR) 1.45; 95% confidence interval (CI) 0.98-2.15; p = 0.065), radiotherapy showed no benefit in patients with stage II disease (HR 0.82; 95% CI 0.62-1.1; p = 0.15). There was a significant survival benefit for patients with stage III disease receiving radiotherapy (HR 0.60; 95% CI 0.41-0.88; p = 0.008).

CONCLUSION

Post-mastectomy radiotherapy is associated with longer OS in male patients with stage III breast cancer. Male breast cancer patients at stages I and II do not seem to benefit from radiotherapy, but obsolete irradiation techniques might explain adverse long-term effects in earlier stages.

Clinical implication of surgical resection for the rare cardiac tumors involving heart and great vessels

This study aimed to investigate the clinical implication of surgical resection for the malignancies of heart and great vessels. Between January 2001 and May 2011, a retrospective review of the results in 12 patients was conducted. There were 6 patients with primary cardiac tumor including leiomyosarcoma, angiosarcoma, undifferentiated type sarcoma and malignant fibrous histiocytoma. The remaining 6 patients had the metastatic tumors or adjacent invasion to the heart and great vessels. Six of seven patients who underwent complete resection had no evidence of recurrence. However, four of five patients who underwent incomplete resection or biopsy showed local recurrence or distant metastasis of residual tumor, and one of them required reoperation for recurred tumor. In-hospital mortality was 8.3% and the mean survival of all patients was 22.2 ± 6.1 months. Survival of the incomplete resection group, except for the two biopsy cases, was 25.9 ± 7.9 months, and there was no mortality in the complete resection group. Therefore, clinical outcomes in patients who had malignancies of the heart and great vessels may be improved when the aggressive and complete resection, or possible debulking for palliation, was performed. Moreover, adjuvant multimodality therapy may be imperative to prevent recurrence or metastasis, and to provide improved survival.