Adjuvant Systemic Therapies in Patients with Colorectal Cancer: An Audit on Clinical Practice in Italy

Aims and Background

Rarely are conclusions from clinical trials summarized in international consensus conferences and promptly transferred to patient care. The adjuvant therapy for colorectal cancer used in daily clinical practice in Italy is described and compared with the recommendations of the 1990 NIH Consensus Conference.

Patients and Methods

We audited prescriptions of adjuvant systemic therapies for Italian colorectal cancer patients in 82 centers during a fixed one-week period.

Results

Among 434 patients receiving adjuvant chemotherapy there were 139 (42.5%) colon cancer patients with N- and 169 (51.7%) with N+ regional nodal involvement. Treatment at academic centers, a young age, T4 and a low total number of lymph nodes removed at surgery were the factors potentially justifying the decision for adjuvant chemotherapy in stage II colon cancer patients. The most common chemotherapy used was a bolus of 5-fluorouracil/folinic acid for 6 months (75.8%). Adjuvant radiotherapy was not administered to 37 (38.5%) of 96 patients with stage II and III rectal cancer.

Conclusions

The study shows that a substantial proportion of patients on adjuvant treatment at a certain time point in a large enough sample of Italian centers are stage II (potential over-treatment) and that an under-treatment of stage II and III rectal cancer patients (lack of radiotherapy) occurs too often in daily clinical practice in this country.

[Alendronate-induced esophagitis. A report of 2 cases]

Two cases of esophagitis associated with the use of alendronate are described. Both patients were women with no past history of heartburn or dyspepsia, who started alendronate for postmenopausal osteoporosis at least one week before the symptoms onset, by taking the drug with half a glass of tap water at bedtime. The first patient suffered from a severe chest pain; endoscopy showed confluent erosions of the lower third of the esophagus. The second patient had odynophagia and developed exudates and greyish plaques on the mucosa of the upper third of the esophagus. Histological examination of the esophageal specimens of both patients disclosed no Monilia, hyphae, or nuclear viral inclusions. Both patients stopped alendronate with complete recovery at follow-up. A brief review of the etiopathogenesis of pill esophagitis is also presented. Finally, emphasis is placed on the selection of patients for therapy with alendronate with warnings on how to take the drug correctly.

Pancreatic carcinoma: differences between patients with or without diabetes mellitus

In order to assess the prevalence and type of diabetes mellitus in patients with pancreatic carcinoma and if the risk factors for the cancer have a different distribution among diabetics and non-diabetics, we reviewed the charts of 127 histologically and/or cytologically proven pancreatic carcinomas consecutively diagnosed from 1977 to 1989 and referred to our Primary Care Hospital from the attending physician. 48 out of 127 (37.7%) subjects were found to be diabetic; 3 had long standing insulin dependent diabetes mellitus, 10 long standing non insulin dependent diabetes mellitus and 35 (73% of all diabetics) new onset diabetes mellitus. 5 out of 10 long standing non insulin dependent diabetics showed secondary failure to oral antidiabetic agents and weight loss in the last six months before the diagnosis of pancreatic carcinoma. When compared to non-diabetics, all diabetics were older (p = 0.05), drank less alcohol (p = 0.047) and had a higher rate of previous neoplasms (p = 0.005). New onset diabetics had a less advanced cancer than those of long standing (p = 0.009). Our study calls for a careful search for pancreatic carcinoma in new onset diabetes of elderly and in long standing, weight losing, non insulin dependent diabetics on secondary failure to oral antidiabetic agents and support the hypothesis that diabetes associated pancreatic carcinoma may bear an its own etiopathogenesis.

Changes in Diagnostic Approach and Factors Affecting Treatment and Survival of Pancreatic Carcinoma in a Retrospective Series over Twelve Years

Aims

Identify the following aspects of pancreatic carcinoma: 1) the prevalence of some risk factors, 2) the accuracy of the diagnostic tecniques and the pattern of their utilization over the years, 3) the factors affecting the therapeutic choice and mortality.

Methods

Retrospective study on all patients with a final diagnosis of pancreatic carcinoma seen at the Ospedale di Busto Arsizio, from January 1978 to August 1989.

Results

There were 155 patients, 68 ±11.6 years old, with a 1.2 male to female ratio. Antemortem pathologic confirmation was obtained in 127 cases (82%); 45% were smokers and 45% drinkers. Diabetes mellitus, a history of peptic disease, a past neoplasm and gallstone disease were respectively present in 36.1%, 12.3%, 11% and 8.2% of the cases; 61.9% 23.8% and 9% of the tumors were located respectively in the head, body and tail; 1.3%, 40% and 51.5% were respectively in stage II, III and IV. Ultrasound abdominal scanning and computerized tomography sensitivity were respectively 67.5% and 72.5% (p = NS). In addition, carcinoembryonic antigen, fine needle aspiration biopsy and percutaneous transhepatic cholangiography showed respectively a 66.6%, 88.9% and 93% sensitivity. Together the non-invasive imaging procedures dramatically decreased the number of unnecessary exploratory laparotomies over the years (p = 0.005) without changing the stage at diagnosis or survival. Among the tested variables (age, sex, year of diagnosis, past diseases, co-morbidity, location and stage of the tumor), only the head location and a less advanced stage were significantly related to a surgical choiche (p< 0.001). Overall one-year survival rate was 13.4%, and among the tested variables, only a less advanced stage and the aggressive treatment were associated to a longer survival (p< 0.001).

Conclusions

The prevalence of diabetes mellitus in patients with pancreatic carcinoma may be higher than previously expected; the wide use of diagnostic imaging, dramatically reduced the number of unnecessary exploratory laparotomies over the years; aggressively treated patients with a less advanced stage have a slight, but significant improvement in survival.

[Digestive hemorrhage secondary to biliary ileus. Endoscopic diagnosis]

A rare case of gastrointestinal hemorrhage is presented. The cause of bleeding was ulcer of the descending duodenum due to erosion of an impacted gallstone. Oral endoscopy made possible a preoperative diagnosis and, pushing the gallstone, made surgery easier. The patient underwent enterolithotomy and had a completely uneventful course.

[The diagnostic use of laparoscopy in liver pathology in light of the evolution of imaging diagnosis]

We considered 87 patients suffering from chronic hepatic pathology. 62 patients have resulted suffering from cirrhosis or chronic active hepatitis, 25 from neoplasias. In the patient's group with chronic liver disease the humoral tests were not able to differentiate between cirrhosis or chronic active hepatitis. In the present retrospective experience echography showed sensibility 0.53 and specificity 0.91. In cirrhosis group, sensibility 0.5 and specificity 0.60 in chronic active hepatitis, sensibility 0.8 and specificity 0.95 in the neoplasia group. Peritoneoscopy showed sensibility 0.97 and specificity 0.93 in the cirrhosis group and sensibility 0.90 and specificity 1.00 in the neoplasia group. We had one case of major complication: hemoperitoneum from tear of adhesion secondary to previous laparotomy. We can conclude that peritoneoscopy is an useful procedure in the study of liver chronic disease and it still finds indication in selected cases of focal illness.

[Peritoneovenous shunt complicating a glomerulonephritis associated with bacteremia. Description of a clinical case]

We report the case of a patient who exhibited a complication following implantation of the LeVeen valve. This is the first example of a delayed complication in our experience, occurring approximately 3 years after the implantation. Biochemical and clinical data showed bacteremia due to meningococci resulting from the valve (and this was subsequently confirmed by microbiological data).