Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

BACKGROUND

Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks.

METHODS

The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned.

RESULTS

A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31).

CONCLUSION

Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov).

Global Forum of Cancer Surgeons: Cancer Surgery During the COVID-19 Pandemic: Impact and Lessons Learned

Background

The purpose of this article is to summarize the opinions of the surgical oncology leaders from the Global Forum of Cancer Surgeons (GFCS) about the global impact of COVID-19 pandemic on cancer surgery.

Methods

A panel session (virtual) was held at the annual Society of Surgical Oncology 2021 International Conference on Surgical Cancer Care to address the impact of COVID-19 on cancer surgery globally. Following the virtual meeting, a questionnaire was sent to all the leaders to gather additional opinions. The input obtained from all the leaders was collated and analyzed to understand how cancer surgeons from across the world adapted in real-time to the impact of COVID-19 pandemic.

Results

The surgical oncology leaders noted that the COVID-19 pandemic led to severe disruptions in surgical cancer care across all domains of clinical care, education, and research. Several new changes/protocols associated with increased costs were implemented to deliver safe care. Leaders also noted that preexisting disparities in care were exacerbated, and the pandemic had a detrimental effect on well-being and financial status.

Conclusions

The COVID-19 pandemic has led to severe disruptions in surgical cancer care globally. Leaders of the GFCS opined that new strategies need to be implemented to prepare for any future catastrophic events based on the lessons learned from the current events. The GFCS will embark on developing such a roadmap to ensure that surgical cancer care is preserved in the future regardless of any catastrophic global events.

Acute abdomen in the immunocompromised patient: WSES, SIS-E, WSIS, AAST, and GAIS guidelines

Immunocompromised patients are a heterogeneous and diffuse category frequently presenting to the emergency department with acute surgical diseases. Diagnosis and treatment in immunocompromised patients are often complex and must be multidisciplinary. Misdiagnosis of an acute surgical disease may be followed by increased morbidity and mortality. Delayed diagnosis and treatment of surgical disease occur; these patients may seek medical assistance late because their symptoms are often ambiguous. Also, they develop unique surgical problems that do not affect the general population. Management of this population must be multidisciplinary.This paper presents the World Society of Emergency Surgery (WSES), Surgical Infection Society Europe (SIS-E), World Surgical Infection Society (WSIS), American Association for the Surgery of Trauma (AAST), and Global Alliance for Infection in Surgery (GAIS) joined guidelines about the management of acute abdomen in immunocompromised patients.

Postpartum nutrition affects the insulin-like growth factor system in dominant follicles and plasma of anestrous beef cows

Effects of nutrition on insulin-like growth factor-I (IGF-I), IGF binding proteins (IGFBP), and insulin in plasma and dominant follicles were evaluated at day 72 and 56 (Exp. 1, n = 12 and Exp. 2, n = 28, respectively) postpartum in anovulatory primiparous beef cows. Cows were stratified based on body condition score at calving and randomly assigned to nutritional treatments: maintain (M), 2.27 kg of a 40 % CP supplement per day and ad libitum hay; or gain (G), ad libitum access to a 50 % concentrate diet and ad libitum hay. Blood samples were collected twice weekly starting 30 days postpartum. Ovarian follicles were evaluated using ultrasonography commencing 42 (Exp. 1) or 30 (Exp. 2) days postpartum. Body weight and condition score were greater (P < 0.05) for cows of G than M groups and postpartum interval to luteal function was longer for cows of the M than G group. Insulin and IGF-I concentrations in follicular fluid (FF) and plasma were greater (P < 0.05) for cows of the G than M group at follicular aspiration. Plasma and FF IGFBP4 and IGFBP5 concentrations were greater (P <  0.05) in Exp. 2, and IGFBP5 was greater in Exp. 1 for cows of the G than M group. Treatment did not affect FF steroid concentrations or granulosal cell CYP19A1, PAPPA, IGFBP4, and IGFBP5 mRNA abundance. These results indicate concentrations of IGF-I, insulin, IGFBP4, and IGFBP5 in FF and plasma are affected by nutritional intake and may be related to follicular function.

Short- and long-term effects of temporary early cow-calf separation or restricted suckling on well-being and performance in zebu cattle

Information on weaning techniques in the tropics is scarce, particularly regarding the long-term effect of temporary early cow-calf separation or restricted suckling. Therefore, we studied the effects of these two handling practices on well-being and performance at 150 days postpartum in fifteen zebu cow-calf pairs randomly assigned to three treatments. Continuous suckling (CS) where calves remained with their dams from birth to weaning; restricted suckling (RS) calves were allowed to suckle 30 min/day from Day 34 until weaning at Day 150 and kept separated the rest of the time; temporary separation (TS) calves were separated for 72 h from their dams from Day 33 to 36 but remained with their dams the rest of the time. Blood samples and behavioral data were collected on Days 32-36 (1st period) and 149-153 (2nd period). In the 1st period, a greater percentage of RS and TS calves were observed close to the fence line (<10 m) that separated them from their dams (P < 0.0001) and vocalized more than CS calves (P < 0.0001), while in the 2nd period, RS calves had the highest cortisol concentration and vocalization rate (P < 0.05). Similarly, during the 1st period, a greater percentage of RS and TS cows were observed close to the fence line than CS cows (P < 0.0001), with TS cows vocalizing the most (P = 0.001). In the 2nd period, RS cows had greater cortisol concentration than TS (P = 0.037) and CS cows (P = 0.003). More TS and CS cows than RS were observed close to the fence line (P = 0.03 and P = 0.05). On Day 150, TS calves and cows vocalized more than RS and CS animals (P < 0.0001). Before calf-cow separation, 27 out of 45 cows were cycling (CS = 10; RS = 6; TS = 11). After separation, 12 of the remaining 18 cows resumed ovarian activity (CS = 3; RS = 5; TS = 4), and all cows were cycling after estrous synchronization treatment. The pregnancy rate was similar between CS, RS, and TS (60, 53, and 60% respectively). In conclusion, temporary separation increased calf distress response to definitive weaning even four months later, while restricted suckling seemed to reduce it.

Hey surgeons! It is time to lead and be a champion in preventing and managing surgical infections!

Appropriate measures of infection prevention and management are integral to optimal clinical practice and standards of care. Among surgeons, these measures are often over-looked. However, surgeons are at the forefront in preventing and managing infections. Surgeons are responsible for many of the processes of healthcare that impact the risk for surgical site infections and play a key role in their prevention. Surgeons are also at the forefront in managing patients with infections, who often need prompt source control and appropriate antibiotic therapy, and are directly responsible for their outcome. In this context, the direct leadership of surgeons in infection prevention and management is of utmost importance. In order to disseminate worldwide this message, the editorial has been translated into 9 different languages (Arabic, Chinese, French, German, Italian, Portuguese, Spanish, Russian, and Turkish).

Abstract P1-07-02: Withdrawn

This abstract was withdrawn by the authors.

Abstract P5-23-01: Clinical and biological characterization of male breast cancer (BC) EORTC 10085/TBCRC 029/BOOG 2013-02/BIG 2-07: Baseline results from the prospective registry

BACKGROUND: Through the International Male Breast Cancer Program, a prospective registry for male BC was created with the goals of evaluating 1) the clinical and biological features of this disease and 2) assessing feasibility of a prospective therapeutic clinical trial.

METHODS: All men, with any stage histologically proven invasive breast cancer, age 3 18 years, and newly presenting at the participating institutions (within 3 months prior) were eligible. Patients were enrolled for 30 months after activation of the first center, through February 2017. Per the study design, if &lt;100 men enrolled, the study would be considered a failure and therapeutic trials would not be pursued through this network. Epidemiologic data, staging, pathologic features, and BRCA status were collected. Treatment and outcome data collection is ongoing. Optional collection of FFPE tumor samples, blood, and QOL were performed in the US, the Netherlands, and Latin America. Clinical database lock for this report was May 30, 2017. We currently report patient and disease characteristics and will update with patterns of treatment for the presentation. Outcomes and biological samples will be analyzed in the future.

RESULTS: 557 patients were enrolled: 75% in Europe, 20% in United States, 5% in other countries. 6.3% of patients had missing forms. Median age was 67 years (range 26-92). 93% were diagnosed 2010-2017. Among patients with complete data, 79% presented with a breast mass. 88% were M0 and 12% M1. Among M0 patients: 47%, 39%, 2%, and 11% had T1, T2, T3, and T4 disease respectively; 52% were N0. Overall, 98% had ER+ disease and 11% had HER2+ cancer. 14% had grade 1, 56% had grade 2, and 30% had grade 3 tumors. Among 112 men who underwent BRCA1 testing, 1 was positive. Among 118 men who had BRCA2 testing, 18 (15%) were positive. 21% of men had prior or concurrent malignancies, with the following most common sites: prostate, non-melanoma skin, colorectal, and melanoma. The prevalence of previously identified possible risk factors for male breast cancer were: overweight/obesity (72%), former/current smoker (51%), current alcohol 31 drink daily (41%), family history of breast cancer (35%), gynecomastia (16%), history radiation exposure (8%), use of anti-androgens (1%), and use of estrogens (1%).

CONCLUSION: Through an international collaborative effort, we were able to prospectively accrue 557 patients to a male breast cancer registry. These results demonstrate feasibility of pursuing a therapeutic clinical trial in men with breast cancer. In addition, this study shows the relatively low uptake of BRCA testing, high rates of concurrent/prior malignancy, and the rates of potentially modifiable risk factors in this patient population.

Funding from Breast Cancer Research Foundation, Susan G. Komen, Dutch Pink Ribbon Foundation, Swedish Breast Cancer Association (BRO) and EBCC Council.

Citation Format: Giordano SH, Schröder CP, Poncet C, van Leeuwen-Stok E, Linderholm B, Abreu MH, Rubio I, Van Poznak C, Morganstern D, Cameron D, Vleugel MM, Smilde TJ, Bozovic-Spasojevic I, Korde L, Russell NS, den Hoed IDM, Honkoop AH, van der Velden AWG, van 't Riet M, Dijkstra N, Bogler O, Goulioti T, Hilsenbeck S, Ruddy KJ, Wolff A, van Deurzen CHM, Martens J, Bartlett JMS, Aalders K, Tryfonidis K, Cardoso F. Clinical and biological characterization of male breast cancer (BC) EORTC 10085/TBCRC 029/BOOG 2013-02/BIG 2-07: Baseline results from the prospective registry [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-23-01.

Angular Leaf Spot of Cucurbits is Associated With Genetically Diverse Pseudomonas syringae Strains

Angular leaf spot of cucurbits is generally considered to be caused by Pseudomonas syringae pv. lachrymans. It has a worldwide distribution and has been observed to emerge sporadically under humid and wet conditions. Reports of multiple P. syringae pathovars associated with the disease and lack of molecular analysis has left the true diversity of populations in the United States unclear. In this study, we collected 27 P. syringae strains causing foliar lesions and blighting on watermelon, cantaloupe, and squash in Florida, Georgia, and California over several years. Strains were fluorescent on King's medium B agar and displayed the typical phenotypic and biochemical characteristics of P. syringae. P. syringae pv. lachrymans is a member of genomospecies 2. However, the genetic profiles obtained through both MLSA (gyrB, rpoD, gapA, and gltA) and BOX-PCR (BOXA1R) identified 26 of the P. syringae strains to be distributed among three clades within genomospecies 1, and phylogenetically distinct from genomospecies 2 member P. syringae pv. lachrymans. A novel MLSA haplotype of the pathogen common to all states and cucurbit hosts was identified. Considerable genetic diversity among P. syringae strains infecting cucurbits is associated with the same disease, and reflects the larger ecological diversity of P. syringae populations from genomospecies 1.

Maternal protective behavior of zebu type cattle (Bos indicus) and its association with temperament

The objective of the study was to evaluate the maternal protective behavior of zebu-type cattle (Bos indicus) and its association with temperament. A total of 40 cow-calf pairs raised under extensive conditions were randomly assigned to 1 of 4 groups (n = 10), which were evaluated at 30, 60, 90, and 120 d postpartum (dpp), respectively. Measures obtained were defense responses of cows protecting their calves assessed by categorizing the behavioral response of the dams during handling of their calves and chute exit score and facial hair whorl (HW) position as indirect measures associated with temperament. No association was found between protective behavior and exit score or HW measures (rs < 0.22 and 0.13, respectively; P > 0.05). At 30 dpp, 90% of the cows responded to the stimulus of calves being handled, 40% reacted exclusively to alien calves, and 50% responded to their own or alien calves. Sixty days later, the proportion of cows responding to alien calves decreased (P < 0.05) to 10%, and at 120 dpp, cows responding to any calf decreased (P < 0.05) to 20%, while the nonresponding cows increased (P < 0.05) to 60%. Similarly, as dpp increased, the intensity of the reaction of the cows to the manipulation of their calves declined. The intensity of the response was exacerbated (P < 0.05) when a human being was less than 1 m distance from the calf, also when the calf was its own or when the calf vocalized. Furthermore, independent of the sex of their own calf, cows reacted more to male than female calves (P < 0.05). It was concluded that zebu cows may display maternal protective behavior to their own or alien calves, which weakens about 120 dpp and is not influenced by individual temperament.

Abstract P1-01-29: Intraoperative molecular analysis of sentinel lymph node as a new predictor of axillary status in early breast cancer patients

The one-step nucleic acid amplification (OSNA) assay (Sysmex Corporation, Kobe, Japan) is a new diagnostic device that uses molecular biological techniques to analyze sentinel lymph node (SLN). Intraoperative SLN assessed by OSNA has been validated as an accurate method for detection of SLN metastasis compared to conventional histological examination. Although recent reports have shown that breast cancer patients with &lt;2 positive SLNs can be spared of a complete axillary lymph node dissection (cALND), there are still a number of patients for whom prediction of non SLN metastasis may be helpful for cALND decision making.

The aim of the present study is to assess the intraoperative positive SLN total tumor load (TTL, defined as the amount of CK19 mRNA copies [copies/μL] in all positive SLNs) obtained by OSNA and to determine whether it is predictive of non-SLNs metastasis independently of the number of affected SLN and the type of surgery.

Data were collected during the month of June 2012 from medical records and include age, tumor size and grade, estrogen and progesterone receptor status, HER2 status, Ki67, presence of lymphovascular invasion (LVI), total number of SLN and non-SLN, number of positive and negative non-SLN, size of SLN and non-SLN metastasis, and TTL in each SLN. A total number of 701 patients were recruited, of which 697 (99,4%) met the study selection criteria. Univariate logistic regression showed that, in addition to TTL (p &lt; 0,001), the number of affected SLNs (p &lt; 0,001), tumor size (p &lt; 0,001), HER2 status (p = 0,007), and LVI (p &lt; 0,001) were predictive of ALND status. The multivariate logistic regression analysis showed that TTL is an independent predictor of metastatic non-SLNs, after adjusting for the tumor size, HER2 status, LVI and, in particular, the number of affected SLNs.

Moreover, the ROC curve analysis showed that, as compared to the number of affected SLN, TTL has a better ROC curve, as measured by the AUC: LogTTL 0.709 (95% CI, 0.667–0.760); number of affected SLN 0.610 (95% CI, 0.570–0.652), p &lt; 0.001. Furthermore, in patients possessing a TTL&lt;15000, the frequency of non-SLN metastasis was 14,7% (NPV = 85,3%, PPV = 41,1%, Sensitivity = 76,7%, Specificity = 55,2%). Taking this value as a cutpoint, 85 patients with mastectomy may have spared a cALND considering the predictive results of the TTL. In seven patients with &gt; 3 positive SLN the TTL was &lt; 15000 so this group, even with 3 positive SLNs, have 14.7% of having additional non SLN metastasis.

In conclusion, TTL by OSNA is a newly standardized, automated, and reproducible tool that predicts axillary node status better and independently of the number of affected SLNs and the type of surgery. This value can then help clinicians to personalize surgical treatment. Prospective studies will be carried out to determine the clinical impact of this variable in the management of patients.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-01-29.

First Report of the Crucifer Pathogen Pseudomonas cannabina pv. alisalensis Causing Bacterial Blight on Radish (Raphanus sativus) in Germany

In 2008, a bacterial blight was observed on Raphanus sativus in the Pfalz region in Germany. Disease was sporadic but severe when present within R. sativus fields, which resulted in unmarketable crops. Symptoms consisted of small, angular, water-soaked flecks that often were surrounded by chlorotic haloes. Lesions were visible from adaxial and abaxial leaf surfaces and generally retained chlorotic borders. A gram-negative, bluefluorescing bacterium was isolated from surface-disinfested leaf tissue on King's medium B agar. The radish isolate was levan positive, oxidase negative, and arginine dihydrolase negative. The isolate did not rot potato slices but induced a hypersensitive reaction in tobacco. These reactions corresponded to Lelliot's LOPAT group 1 (2). Repetitive extragenic palindromic sequence (rep)-PCR assays using the BOXA1R primer resulted in different DNA fragment banding patterns between the radish isolate and the pathotype strain of Pseudomonas syringae pv. maculicola (CFBP 1657), but identical DNA fragment banding patterns between the radish isolate and the pathotype strain of P. cannabina pv. alisalensis (CFBP 6866). Unlike P. syringae pv. maculicola, P. cannabina pv. alisalensis and the radish isolate were lysed by bacteriophage PBS1 (1). Pathogenicity was evaluated on two hosts, radish (R. sativus cv. Comet) and broccoli raab (Brassica rapa cv. Sorrento). In each of two independent experiments, 3-week-old radish and broccoli raab plants were inoculated with either the radish isolate, P. cannabina pv. alisalensis, or P. syringae pv. maculicola. Inoculum was prepared by growing the bacteria on nutrient agar for 48 h at 27°C, suspending the bacteria in 0.01 M phosphate buffer (pH 7.0), and adjusting each suspension to 0.6 OD at 600 nm (approximately 1 × 10⁸ CFU/ml). All plants were inoculated by spraying until runoff, incubated in a humidity chamber for 48 h, then placed in a greenhouse at 20 to 25°C for symptom development. Plants inoculated with P. cannabina pv. alisalensis or sprayed with buffer served as positive and negative control treatments, respectively. Seven to ten days postinoculation, the development of symptoms similar to those originally observed in the field were observed on plants inoculated with the radish isolate. In addition, symptoms on radish and broccoli raab plants caused by the radish isolate were similar to symptoms caused by P. cannabina pv. alisalensis in contrast to the lack of symptoms on plants inoculated with P. syringae pv. maculicola. Bacteria isolated from symptomatic tissue and surface-disinfested with sodium hypochlorite (0.525%) had identical characteristics to the radish isolate used to inoculate plants and to the P. cannabina pv. alisalensis pathotype for LOPAT reactions, rep-PCR DNA fragment banding pattern analysis, and sensitivity to phage PBS1, thus fulfilling Koch's postulates. To our knowledge, this is the first report of P. cannabina pv. alisalensis isolated from diseased crucifers in Germany. Verification of P. cannabina pv. alisalensis in Germany indicates that German crucifer growers should differentiate between outbreaks caused by P. cannabina pv. alisalensis and P. syringae pv. maculicola and apply appropriate, specific management strategies. References: (1) C. T. Bull et al. Syst. Appl. Microbiol. 33:105, 2010. (2) R. A. Lelliott. J. Appl. Bacteriol. 29:470, 1966.

First Report of Bacterial Blight of Crucifers Caused by Pseudomonas cannabina pv. alisalensis in Australia

In 1978 and 1979, Pseudomonas syringae pv. maculicola strains DAR 33362, DAR 33363, and DAR 33406 were isolated from diseased Brassica hirta, B. nigra, and B. napus var. napus, respectively, in Wagga Wagga and Armatree, NSW, Australia (2). Peters et al. (2) demonstrated that these strains were similar to P. syringae pv. maculicola ICMP 4326 (CFBP 1637), which was recently transferred to Pseudomonas cannabina pv. alisalensis (1). We evaluated these Australian strains to determine if they might also be P. cannabina pv. alisalensis. Amplification of DNA using the BOXA1R primer and PCR resulted in identical DNA fragment banding patterns for Australian strains DAR 33362 and DAR 33363 and P. cannabina pv. alisalensis ICMP 4326 and CFBP 6875. The third Australian strain, DAR 33406, was 90% similar to P. cannabina pv. alisalensis; in contrast, it was only 77% similar to P. syringae pv. maculicola. All strains of P. cannabina pv. alisalensis, including the pathotype strain (CFBP 6866) and all three Australian strains, were lysed by bacteriophage PBS1, which is specific for P. cannabina pv. alisalensis strains (1). To complete Koch's postulates, pathogenicity was evaluated on B. hirta, B. nigra, and B. napus var. napus. In two independent experiments, two plants of each species were inoculated with each Australian strain or a phosphate buffer control treatment. In separate experiments, pathogenicity was evaluated on the differential hosts radish (Raphanus sativus cv. Comet) and broccoli raab (Brassica rapa cv. Sorrento), and plants inoculated with the pathotypes of P. cannabina pv. alisalensis and P. syringae pv. maculicola served as additional control treatments. Inoculum was prepared by growing the bacteria on nutrient agar for 48 h (27°C), suspending the bacteria in 0.01 M phosphate buffer (pH 7.0), and adjusting each suspension to 0.6 OD at 600 nm (approximately 10⁸ CFU/ml). Treatments were applied by spraying until runoff. DAR 33362, DAR 33363, and DAR 33406 caused typical bacterial blight symptoms on B. hirta, B. nigra, and B. napus var. napus. Infected leaves became yellow, followed by the development of small (<2 mm in diameter), angular, water-soaked, and eventually, shot-holed spots. Bacteria isolated from symptomatic tissue following surface disinfestation of tissue with sodium hypochlorite (0.525%) had identical characteristics (rep-PCR DNA fragment banding patterns and phage sensitivity) to the strains used to inoculate the plants. Additionally, DAR 33362, DAR 33363, and DAR 33406, as well as P. cannabina pv. alisalensis, caused symptoms on radish and broccoli raab while P. syringae pv. maculicola and the buffer control did not. These data support the transfer of the Australian crucifer strains, originally identified as P. syringae pv. maculicola, to P. cannabina pv. alisalensis. To our knowledge, this is the first report of a bacterial disease of crucifers caused by P. cannabina pv. alisalensis in Australia. Differentiation of these pathogens will inform crop rotation strategies for disease management. References: (1) C. T. Bull et al. Syst. Appl. Microbiol. 33:105, 2010. (2) B. J. Peters et al. Plant Pathol. 53:3, 2004.

Percutaneous transhepatic biliary drainage (PTBD) and endoscopic retrograde cholangiopancreatography (ERCP) for malignant obstructive jaundice (OJ) in advanced digestive cancers

348

Background: OJ is a relatively frequent complication in patients with advanced malignancies that usually causes refractory symptoms and can make chemotherapy (CT) treatment difficult. In the last years, the use of different non-surgical techniques, such as PTBD or ERCP, is increasing.

Methods: From Sep-05 to Aug-10, patients with OJ due to advanced digestive cancers who underwent ERCP or PTBD were included. Baseline characteristics, acute and late complications and outcome were retrospectively collected. Jaundice resolution was recognized if bilirubin value decreased to at least grade 1, after the procedure. Overall survival (OS) was calculated from the date of the technique to the date of death or last follow-up.

Results: Seventy-six consecutive patients were collected. Male/Female: 52p/24p; Mean age 63.5 y-o (range: 33-85); ECOG performance status 0/1/2/3: 1/37/27/11; Primary tumour: pancreas 30, biliary tract 18, colorectal 16, gastric 7, and gall bladder 5, and of them, 13% were unresectable locally advanced and 87% metastatic. ERCP was used in 59% of the patients and PTBD in 49% and the proportion of intrahepatic and extrahepatic causes were 1:1. Mean hospital stay was 11.3 days (95% CI 1-21). Twenty- six patients (32%) suffered a complication during the hospital stay: 9 cholangitis, 7 catheter obstruction, 2 bleeding, 2 acute pancreatitis and 6 other, and 8 died of procedure-related adverse event. After hospital discharge there were 34% infections, 17% catheter obstruction and 8% other. After the technique OJ was solved (bilirubin nadir) in 49% of the patients and 55% underwent palliative CT. Median OS was 30 weeks (95% CI: 17-42).

Conclusions: PTBD and ERCP are appropriate techniques in patients with malignant OJ and can resolve an absolute contraindication for palliative CT. However, major complications are frequent and a relatively high mortality rate should be expected. Therefore an adequate patient selection is crucial to prevent adverse events.

No significant financial relationships to disclose.

Second-line chemotherapy with capecitabine (CAP) and oxaliplatin (OX) in patients with pancreatic or biliary tree adenocarcinoma (ADC)

308

Background: Pancreatic and biliary tree ADC represent poor prognostic tumors. Gemcitabine is usually considered the first- line chemotherapy and after that no standard treatment has been established. CAP and OX have demonstrated some activity in metastatic (M1) and locally advanced (LA) pancreatic cancer, and the combination of these drugs confers additional benefit as well. We conducted this study in order to establish the efficacy of this schedule on pancreatic and biliary tree ADC.

Methods: Pts with M1 or LA pancreatic or biliary tree ADC with progression to one previous chemotherapy treatment were included. Performance status≤2, age≥18 years and adequate renal and hepatic function were selected. Schedule of chemotherapy: CAP 1000 mg/m2 bid on days 2 to 15 and OX 130 mg/m2 on day 1 of a 3-week cycle. RECIST criteria were used for assessment of response and NCI-CTCAE v 3.0 for toxicity.

Results: Between April 2006 and March 2010, 40 pt were included. Male/female: 29/11. Mean age: 60.7 years (37-74). Pancreatic/biliary: 23/17. PS 0/1/2: 3/27/10. LA/ M1: 1/39. Mean number of cycles: 2.50 (1-10). Disease response per pt, partial/ stable disease/progression/not evaluated: 1/9/21/9. Tumor control (partial/stable disease): 10 pt (22%). Hematologic toxicity (grade1/2/3/4) (%) per pt: neutropenia 5/2.5/7.5/0; thrombocytopenia 15/5/2.5/5; anemia 42.5/10/52.5/0. Nonhematologic toxicity (grade 1/2/3) (%) per pt: asthenia 10/45/17.5; emesis 22.5/15/2.5.; anorexia 12.5/35/7.5; diarrhea 7.5/12.5/5; neurotoxicity 42.5/17.5/2.5; hand-foot syndrome 5/2.5/2.5. One toxic death was reported. Median time to progression: 15 weeks (95% CI 6.6-23.3). Median survival time: 19 weeks (95% CI 10.4-27.5). For pts with PS0 or 1 median overall survival was 23 weeks (95% CI 6.3-39.6) and for pts with PS2 was 8 weeks (95% CI 5.3-1.6) (p 0.004).

Conclusions: Advanced pancreatic and biliar ADC have unfavorable prognosis. After first-line treatment, CAPOX shows a tolerable toxicity and some activity and it can represent an alternative on selected pretreated pts.

No significant financial relationships to disclose.

Modulation of mu opioid receptor desensitization in peripheral sensory neurons by phosphoinositide 3-kinase gamma

G protein-coupled opioid receptors undergo desensitization after prolonged agonist exposure. Recent in vitro studies of mu-opioid receptor (MOR) signaling revealed an involvement of phosphoinositide 3-kinases (PI3K) in agonist-induced MOR desensitization. Here we document a specific role of the G protein-coupled class IB isoform PI3Kgamma in MOR desensitization in mice and isolated sensory neurons. The tail-withdrawal nociception assay evidenced a compromised morphine-induced tolerance of PI3Kgamma-deficient mice compared to wild-type animals. Consistent with a role of PI3Kgamma in MOR signaling, PI3Kgamma was expressed in a subgroup of small-diameter dorsal root ganglia (DRG) along with MOR and the transient receptor potential vanilloid type 1 (TRPV1) receptor. In isolated DRG acute stimulation of MOR blocked voltage-gated calcium currents (VGCC) in both wild-type and PI3Kgamma-deficient DRG neurons. By contrast, following long-term opioid administration the attenuating effect of MOR was strongly compromised in wild-type DRG but not in PI3Kgamma-deficient DRG. Our results uncover PI3Kgamma as an essential modulator of long-term MOR desensitization and tolerance development induced by chronic opioid treatment in sensory neurons.

Pregnancy after Breast Cancer in Young Patients Does Not Worsen the Outcome of Breast Cancer

Background: Pregnancy after breast cancer may worsen the outcome of breast cancer due to associated hormonal changes, especially among young patients. However, prior studies have failed to detect this effect, which may be explained by the selection of patients of older age and those that gave birth to term. The aim of this study is to assess the effects of pregnancy on the outcome of breast cancer in young patients.Patients: One hundred twenty three young patients (≤35 years) with invasive breast cancer or ductal carcinoma in situ treated consecutively at our hospital between 1995 and 2005. Pregnancy was discouraged during the first two years, but not specific recommendation was given thereafter.Methods: We compared the prognostic factors, treatment with adjuvant chemotherapy treatment and follow-up between patients with pregnancy after breast cancer (P) and those who have not had subsequent pregnancy (NP).Results: There were 20 patients that get pregnant (16%). Of them, eight (40%) decided to interrupt pregnancy, and twelve (60%) gave birth to the term. The average time between diagnosis of cancer and pregnancy was four years. Several prognostic factors, such as age at diagnostic (median age 31 years old in both groups), histological type (CDI in P81% NP83.2%), clinical stage(P: 0 9.5%, I 38.1%, IIA 42.9%, IIIA 9.58%; NP: 0 7.9%, I 23.8%, IIA 32.7%, IIB 16.8%, IIIA 8.9%, IIIB 5.9%, IV 1%), positive axillary lymph nodes (P: 44.4% NP: 51.7%), histological high grade (P: 52.9% NP: 50.6%) and use of chemotherapy (P:76.2 NP: 89.2%) were similar among pregnant and non-pregnant women with differences who was not stadistical significance. However, use of hormonal treatment were more frequent in patients without later gestation (P: 33.% NP 68% p=0.003). Ductal Carcinoma in situ is more frequent among patients wit pregnancy but the difference is not statistical significant (P: 14% NP 4% p=0.10). Patients with pregnancy had better disease-free interval at 5 years (P95% vs NP62% p = 0.003) and overall 5 years survival(100% vs. 82% p = 0.008).Conclusions: A significant proportion of patients diagnosed of breast cancer at young age get pregnant, many of them unwillingly. Our study shows that pregnancy does not seem to worsen outcome. Patients should be counselling do not discontinuing her pregnancy.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2062.

Potential diagnostic markers in bronchial fluid of small cell lung cancer (SCLC)

e22221

Background: Lung cancer is a major cause of mortality worldwide and overall survival rate has not improved significantly over the past 20 years. An early diagnosis could improve prognosis and survival among these patients. The aim of this study was to identify protein markers obtained from bronchial fluids of SCLC patients which may differ from non-pathological bronchoscopy samples. Methods: We have included 43 patients with SCLC diagnosed using bronchoscope and 49 consecutive patients with non pathological bronchoscopy. Bronquial fluid was obtained from each patient and potential protein markers were studied. After being centrifuged, supernatant proteins were analysed using bidimensional electrophoresis with poliacrilamid gel stained with silver nitrate. Gel was scanned and analysed with Progenesis PG6220 program, which measures intensity of each spot. Resultant intensities in each group of patients (SCLC/non pathological bronchoscopy) were compared using T-Student method. We selected as potential markers those spots with a p value of less than 0.05. We calculated “fold change” of each spot as the ratio between mean intensity in SCLC bronchoscopy samples and non pathological bronchoscopy samples. Results: Optimal bidimensional gels of each sample were obtained. Among 300 comparable spots, 10 of them were expressed with a different intensity in both groups of patients; 6 of these potential markers were over expressed in SCLC samples, whereas 4 of them were underexpressed. The “fold change” of these 10 spots ranges from 1.5 to 8.67. Conclusions: Different protein markers can be detected in bronchial fluid obtained from SCLC samples. Significant differences in expression of these biomarkers were detected between SCLC patients and non pathological bronchoscopy patients. The development of an early diagnostic test using these proteins must be validated in future studies.

No significant financial relationships to disclose.