Familial adenomatous polyposis: clinical presentation, detection and surveillance

Colorectal cancer (CRC) is a leading cause of cancer related death in the western countries. It remains an important health problem, often under-diagnosed. The symptoms can appear very late and about 25% of the patients are diagnosed at metastatic stage. Familial adenomatous polyposis (FAP) is an inherited colorectal cancer syndrome, characterized by the early onset of hundred to thousands of adenomatous polyps in the colon and rectum. Left untreated, there is a nearly 100% cumulative risk of progression to CRC by the age of 35-40 years, as well as an increased risk of various other malignancies. CRC can be prevented by the identification of the high risk population and by the timely implementation of rigid screening programs which will lead to special medico-surgical interventions.

Quality of care indicators in rectal cancer

Quality of health care is a hot topic, especially with regard to cancer. Although rectal cancer is, in many aspects, a model oncologic entity, there seem to be substantial differences in quality of care between countries, hospitals and physicians. PROCARE, a Belgian multidisciplinary national project to improve outcome in all patients with rectum cancer, identified a set of quality of care indicators covering all aspects of the management of rectal cancer. This set should permit national and international benchmarking, i.e. comparing results from individual hospitals or teams with national and international performances with feedback to participating teams. Such comparison could indicate whether further improvement is possible and/or warranted.

Prospective randomized study comparing hepatic intra-arterial injection of Yttrium-90 resin-microspheres (HAI-Y90) with protracted IV 5FU (5FU CI) versus 5FU CI alone for patients with liver-limited metastatic colorectal cancer (LMCRC) refractory to standard chemotherapy (CT)

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Background: Chemorefractory LMCRC has a poor prognosis. We hypothesized a significant improvement of the patient's outcome after internal radiotherapy of the hepatic metastases with HAI-Y90 given along with 5FU CI over 5FU CI alone. Methods: This prospective, multicentric, randomized trial compared arm A: 5FU CI (300 mg/m2 D1–14 q3weeks) with arm B: HAI-Y90 and 5FU CI (225 mg/m2 D1–14 followed by 300 mg/m2 D1–14 q3weeks) until disease progression. Eligibility criteria were: chemo-refractory (5FU, oxaliplatin, irinotecan) LMCRC, PS max 2, normal direct bilirubin, and no lung shunting. Primary endpoint was time to liver progression (TTLP). Secondary endpoints were time to progression (TTP), overall survival (OS) and safety. Cross-over (HAI-Y90 monotherapy) was permitted in arm A after disease progression. Analysis was by intention to treat. To detect an increase in median TTLP from 6 to 18 weeks, 35 local progressions were needed (alpha 5%, power 90%). Distribution of time to events variables was modelled through Cox regression (likelihood ratio tests). Results: Trial randomized 46 patients (pts) of whom 44 were eligible for analysis (23 in arm A and 21 in arm B). Pts’ characteristics in the 2 arms were well balanced. Local progression was documented in 41 pts. Median length of follow-up was 108 weeks. Results are summarized in the table . Treatment was well tolerated with few side effects reported, essentially grade 3 asthenia (5 pts; 22%) in arm A. Most pts (25/44) received further treatment after local progression, including 10 pts with cross-over to HAI-Y90 in arm A, which may explain to some degree the lack of difference in OS. Conclusions: HAI-Y90 with 5FU CI significantly improves TTLP and TTP over 5FU CI alone and is a valid salvage therapeutic option for chemo-refractory LMCRC.

[Table: see text]

No significant financial relationships to disclose.

FDG PET predicts prognosis of patients with resectable metastatic colorectal cancer (CRC) treated with preoperative chemotherapy

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Background: Standard evaluation of response to chemotherapy in metastatic CRC is unsatisfactory. Metabolism based imaging using positron emission tomography and fluorodeoxyglucose (FDG-PET) is increasingly used to assess treatment efficacy. Aim: To evaluate the prognostic value of FDG-PET metabolic response to chemotherapy in resectable metastatic CRC. Methods: We reviewed retrospectively 382 patients with metastatic CRC between 7/2002 and 8/2006. Patients curatively operated from CRC metastases treated with preoperative chemotherapy and evaluated by FDG PET at baseline and before surgery were considered eligible for the study. Time to progression (TTP) was defined as the time between surgery and the first proof of recurrence of disease. Total Lesion Glycolysis (TLG) was used as the metabolic parameter. It represents the product of the mean standardised FDG uptake (SUV) of each lesion and its volume. The change of the sum of the TLG of all lesions was calculated. A cut-off of 30% was used to differentiate responders and non- responders. Results: 18 patients (median age 65 yrs) were included. 16 patients were operated from liver mets, and 2 from lung mets. Chemotherapy regimen was FOLFOX 4 in 10 patients, FOLFIRI in 7, and FOLFIRI-bevacizumab in 1 patient. Median number of lesions was 3 (1 to 10) before and 1 after chemotherapy. Median baseline TLG was 115.8 (6.8–841.8). Median post chemo TLG was 12.8 (0–1608.9). The distribution of the metabolic responses was CR 5, PR 9, SD 1, PD 3, with a response rate of 14/18 (78%, 95% CI : 52%-94%). Baseline TLG was not different between responders and non responders (p=0.88). Median follow-up was 422 days: 6 patients died, 15 had recurrent disease. Median TTP was 31 days for non responders, and 197 days for responders (p value not calculated because of the small number of non responding patients). After dichotomization of TLG values using their median as threshold, the post chemo TLG influenced significantly TTP (p=0.001, median TTP 86 days vs 263 days) along with the change of TLG (p=0.002, 107 days vs 263 days). Conclusions: Metabolic response assessment using PET allows a prognostic stratification after preoperative chemotherapy in resectable metastatic CRC.

No significant financial relationships to disclose.