Observation versus late reintroduction of letrozole as adjuvant endocrine therapy for hormone receptor-positive breast cancer (ANZ0501 LATER): an open-label randomised, controlled trial

BACKGROUND

Despite the effectiveness of adjuvant endocrine therapy in preventing breast cancer recurrence, breast cancer events continue at a high rate for at least 10 years after completion of therapy.

PATIENTS AND METHODS

This randomised open label phase III trial recruited postmenopausal women from 29 Australian and New Zealand sites, with hormone receptor-positive early breast cancer, who had completed ≥4 years of endocrine therapy [aromatase inhibitor (AI), tamoxifen, ovarian suppression, or sequential combination] ≥1 year prior, to oral letrozole 2.5 mg daily for 5 years, or observation. Treatment allocation was by central computerised randomisation, stratified by institution, axillary node status and prior endocrine therapy. The primary outcome was invasive breast cancer events (new invasive primary, local, regional or distant recurrence, or contralateral breast cancer), analysed by intention to treat. The secondary outcomes were disease-free survival (DFS), overall survival, and safety.

RESULTS

Between 16 May 2007 and 14 March 2012, 181 patients were randomised to letrozole and 179 to observation (median age 64.3 years). Endocrine therapy was completed at a median of 2.6 years before randomisation, and 47.5% had tumours of >2 cm and/or node positive. At 3.9 years median follow-up (interquartile range 3.1-4.8), 2 patients assigned letrozole (1.1%) and 17 patients assigned observation (9.5%) had experienced an invasive breast cancer event (difference 8.4%, 95% confidence interval 3.8% to 13.0%, log-rank test P = 0.0004). Twenty-four patients (13.4%) in the observation and 14 (7.7%) in the letrozole arm experienced a DFS event (log-rank P = 0.067). Adverse events linked to oestrogen depletion, but not serious adverse events, were more common with letrozole.

CONCLUSION

These results should be considered exploratory, but lend weight to emerging data supporting longer duration endocrine therapy for hormone receptor-positive breast cancer, and offer insight into reintroduction of AI therapy.

CLINICAL TRIALS NUMBER

Australian New Zealand Clinical Trials Registry (www.anzctr.org.au), ACTRN12607000137493.

Portal vein angioplasty using a transjugular, intrahepatic approach for treatment of extrahepatic portal vein stenosis after liver transplantation

Symptomatic portal vein stenosis is an uncommon complication after liver transplantation. Portal vein angioplasty has been successfully established for treatment of portal vein stenosis using mesenteric or percutaneous, transhepatic approaches. We herein report on a patient who suffered from variceal bleeding due to portal hypertension 3 months after liver transplantation. After successful endoscopic sclerotherapy, an extrahepatic portal vein stenosis was diagnosed, and portal vein angioplasty was considered as primary therapeutic option. Instead of mesenteric or percutaneous, transhepatic approaches, we adopted a transjugular, intrahepatic access to introduce a 14-mm balloon catheter into the portal vein. Using this technique, angioplasty was successfully performed. After intervention, no further episodes of variceal bleeding occurred. We favour the transjugular, intrahepatic technique for portal vein angioplasty because it does not require general anesthesia, in contrast to the mesenteric approach, and it reduces the risk of intra-abdominal bleeding, compared to the percutaneous, transhepatic approach.

Results of liver transplantation in acute liver failure caused by viral hepatitis

Fulminant liver failure due to acute viral hepatitis is the most common emergency indication for liver transplantation. The postoperative course is highly correlated with the type and duration of infection. The complication rate is lowest in fulminant hepatitis B patients and highest in subacute hepatitis C/NANB patients.

Extended resections for hilar cholangiocarcinoma

OBJECTIVE

To evaluate different strategies for extended resections of hilar cholangiocarcinomas on radicality and survival.

SUMMARY BACKGROUND DATA

Surgical resection of hilar cholangiocarcinoma is the only potentially curative treatment. Resection of central bile duct carcinomas, however, cannot always comply with the general principles of surgical oncology to achieve wide tumor-free margins with no-touch techniques.

METHODS

From 1988 to 1998, 95 patients underwent resection of hilar cholangiocarcinoma. Eighty patients had hilar and hepatic resections and 15 had liver transplantation and partial pancreatoduodenectomy (LTPP; i.e., eradication of the entire biliary tract using a no-touch technique).

RESULTS

The 60-day death rate was 8%. The overall 1- and 5-year survival rates were 67% and 22%, respectively. Five-year survival rates after R0, R1, and R2 resections were 37%, 9%, and 0%. In a multivariate analysis, surgical radicality was the strongest determinant of survival (p < 0.001). The rate of formally curative resection (R0 resection) was significantly lower in hilar resections (29%) than in liver resections (left hemihepatectomy 59%, right hemihepatectomy 55%, right trisegmentectomy 65%; p < 0.05). The highest rate of R0 resection was observed after LTPP (93%; p < 0.05). Right trisegmentectomies achieved the highest rate of 5-year survival after R0 resection (57%). In a multivariate analysis of patient survival after R0 resection, additional portal vein resection was the only significant factor. The 5-year survival rate after formally curative liver resection with portal vein resection was 65% versus 28% without.

CONCLUSION

Extended resections, especially right trisegmentectomies and LTPP, resulted in the highest rate of R0 resection. Right trisegmentectomy together with portal vein resection best represents the principles of surgical oncology and may be regarded as the surgical procedure of choice. Immunosuppression limits the applicability of LTPP.

p53 mutagenesis in Klatskin tumors

Mutagenesis of the p53 tumor-suppressor gene represents the most common genetic alteration in human malignancies but has not yet been investigated in Klatskin tumors. Cancerous and normal liver tissues were obtained from 12 patients after surgical resection of Klatsin tumors. Genomic DNA was extracted and served as a template for PCR amplification and sequencing of a 1,574-bp fragment of the p53 gene comprising the exons 5 through 8. Immunohistochemical expression analysis was performed using five different antibodies. Missense mutations were detected in 2 of 12 patients--one transversion on codon 273 (Arg --> Leu) and a transition on codon 168 (His --> Arg). In all specimens, immunohistochemistry was negative regarding a nuclear overexpression. An apparent clinicopathologic impact of p53 mutations was not observed. This report on mutagenesis of the p53 gene in Klatskin tumors shows that the most commonly mutated tumor suppressor gene in human cancers is also mutated in a subset of patients with Klatskin tumors. Assessment of a clinical or pathological impact of p53 mutagenesis on Klatskin tumors requires evaluation in larger studies.

Orthotopic liver transplantation after extended bile duct resection as treatment of hilar cholangiocarcinoma. First long-terms results

Although the surgical treatment of hilar cholangiocarcinoma represents the only potentially curative option, survival figures remain low over the long term. After hilar and partial hepatic resections for hilar cholangiocarcinoma, loco-regional tumor recurrence appears as the primary site of failure. From April 1992 to April 1996, 14 patients underwent extended bile duct resections. Extended bile duct resections combine total hepatectomy, partial pancreatoduodenectomy, and liver transplantation in an attempt to eradicate the entire biliary tract without dissecting the hepatoduodenal ligament. The postoperative 60-day mortality rate was 14% (n = 2). The rate of curative resections was 93% (13 of 14 extended bile duct resections). One- and 4-year survival rates after curative resections were 56% and 30%, respectively. The rate of curative resections increased by combining total hepatectomy, partial pancreatoduodenectomy, and liver transplantation, i.e., extended bile duct resection. However, survival figures have not improved accordingly. Therefore, this extended surgical procedure has to be implemented with caution and possibly not without modifications (e.g., multimodal treatment).

Recurrence-free survival after liver transplantation for small hepatocellular carcinoma

Recurrence-free survival (RFS) in patients with small hepatocellular carcinoma (HCC) after orthotopic liver transplantation (OLT) was analyzed. From 1988 until 1996, 725 OLTs were performed in 669 patients. In 52 adults, HCC was confirmed histologically. OLT was limited to patients with small (< 5 cm) HCC with a maximum number of three nodules. Actuarial survival for these 52 patients at 1 and 5 years is 88% and 71%. RFS was defined as time until death without recurrence time until follow up with a diagnosis of recurrence, or, in patients without recurrence, time of last follow up. Overall, the 5-year RFS was 60%. Five-year RFS was less for bilobar compared to unilobar tumors (36% vs 70%), less for stage IVa tumors (UICC) compared to stage I-III tumors (17% vs 71%), and less for multiple compared to solitary tumors (54% vs 67%). In conclusion, potential cure may be achieved in more than 50% of all transplanted patients.

[Extent of resection in surgical therapy of central bile duct carcinomas]

The introduction of a radical procedure, the extended bile-duct resection, into the surgical treatment of hilar cholangiocarcinoma significantly increased the rate of curative resections (92% versus 62% after partial hepatic resection; p < 0.05). A comparable effect with respect to survival figures after curative resections did not become evident. Therefore, the true potential of this extended surgical procedure remains to be established.

[Bile duct carcinoma in an adenoma in the anastomotic area after hepaticojejunostomy--a case report]

Cholangiocarcinoma at the choledochoduodenal anastomosis site is a rare complication. Our 71-years-old female patient developed an adenocarcinoma 38 years after cholecystectomy and choledochoduodenal anastomosis. During the previous two years she suffered from recurrent episodes of cholangitis and jaundice. Multiple endoscopically obtained biopsies from a suspicious area at the anastomosis showed a tubular adenoma. With a CA19-9 of 2,429 U/l laparotomy was performed with radical removal of the choledochoduodenostomy and the extrahepatic bile ducts and reconstruction with hepaticojejunostomy. The histological examination revealed a poorly differentiated, partly solid, partly tubular adenocarcinoma of the choledochal duct with metastasis of the lymph nodes in the hepatoduodenal ligament. According to the UICC staging system the tumor was pT2, G3, pN1 classified as stage III. Two months later the patient developed a peritoneal carcinosis with a CA19-9 of 15,050 U/l and died. The development of cholangiocarcinoma may be caused by chronic cholangitis, which may arise from several diseases of the bile ducts like choledochal cysts, primary sclerosing cholangitis or reflux of duodenal contents like in choledochoduodenal anastomoses. Because of the heterogeneity inside the lesions a malignant lesion can only be excluded by histopathological examination of the whole tumor.

p53 hot-spot mutational analysis in advanced Western gallbladder carcinoma

In gallbladder carcinoma, studies on the prime target of genetic alterations and gene therapy in human gallbladder malignancies, the p53 tumor suppressor gene, have been focusing on this gene's immunohistochemical detection. From November 1991 to October 1993, seven patients suffering from gallbladder carcinoma underwent surgical resection. Cancerous and normal liver tissues were obtained immediately after surgery, snap-frozen in liquid nitrogen, and stored at -80 degrees C for immunohistochemistry and DNA isolation. Exons 5, 6, 7, and 8 of the p53 gene were completely sequenced following polymerase chain reaction (PCR) amplification of a 1574-bp fragment. Missense mutations were detected in the cancerous tissues of two patients: one transition each on codons 134 (Phe-->Leu) and 146 (Trp-->Arg). Immunohistochemical p53 staining was positive in the latter patient only. This is the first report on sequence analysis and mutagenesis of the p53 gene in Caucasian patients with gallbladder cancer. Both mutations were transitions and seem to represent a rather rare event. The possible impact of p53 mutagenesis on gallbladder tumorigenesis requires evaluation in larger studies.

Female sex hormone receptor status in advanced hepatocellular carcinoma and outcome after surgical resection

BACKGROUND

There is a limited amount of data regarding the estrogen receptor (ER) and progesterone receptor (PgR) status of hepatocellular carcinomas (HGCs), and the relationship between receptor status and clinicopathologic features of tumors has not been reported.

METHODS

Between April 1992 and December 1993, cancerous tissues for cytosolic preparation and receptor quantification in a monoclonal solid-phase enzyme immunoassay were obtained from 28 patients undergoing resection, three patients with total hepatectomy and subsequent liver transplantation, and two patients suffering from nonresectable HCC.

RESULTS

ER and PgR were detected in the HCCs of 13 (39%) and 6 patients (18%), respectively. A lower age was observed among the female patients whose receptor status was negative for ER or PgR or both, as compared with the respective receptor-positive groups. No significant differences with respect to tumor stage and grading could be observed. There was one perioperative death (3%). In patients undergoing curative resection, 1-year survival in the ER(+) group was significantly lower than in the ER(-) group (40% versus 79%, p < 0.05). The 2-year survival rates in the ER(+) and ER(-) groups were 40% and 71%, respectively. A comparable trend did not become evident for PgR(+) and PgR(-) patients.

CONCLUSIONS

Our data suggest a negative effect of an ER(+) tumor on patient survival after curative resection of advanced HCC.

Conversion to tacrolimus after liver transplantation

We have reviewed our experience with conversion to tacrolimus after 435 liver transplantations. Tacrolimus was administered as a rescue agent in 33 patients until October 1993. Indications for rescue therapy were: cholestatic forms of severe, steroid-resistant cellular rejection (n = 8), OKT3-resistant cellular rejections (n = 6), cellular rejections in patients suffering from cyclosporin malabsorption (n = 4), late onset cellular rejections (n = 4), early chronic rejections (n = 3), and chronic vascular or ductopenic rejections (n = 8). Response was evident in 29 of the 33 patients (88%), whereas 4 patients (12%) were nonresponsive. Patient and graft survival were 76% and 70%, respectively. Graft loss with or without patient death occurred in three of eight patients suffering from severe, steroid-resistant cellular rejection, in two of six patients with OKT3-resistant cellular rejections, and in five of eight patients undergoing chronic rejection. In severe steroid-resistant cellular rejection, successful tacrolimus rescue therapy corresponded to a significantly lower total serum bilirubin than unsuccessful therapy (12.0 +/- 5.6 mg% vs 29.7 +/- 5.9 mg%, P < 0.05). We conclude that tacrolimus rescue therapy is a safe and efficient alternative for high-risk cases that do not respond to conservative treatment. In severe, steroid-resistant cellular rejection and in chronic ductopenic rejection, conversion to tacrolimus is beneficial only in a limited number of cases. A predictive parameter, which total serum bilirubin may prove to be in severe, steroid-resistant cellular rejection, is needed to select those cases that might benefit more from retransplantation than from conversion to tacrolimus.

The importance of late infections for the long-term outcome after liver transplantation

We investigated the late infections of 400 consecutive liver transplantations performed in 368 patients. After a mean follow-up of 45 months, a total of 180 late infections occurred in 110 liver recipients. Frequent agents were CMV, enterococcus, candida and staphylococcus. Pneumonia was the most dangerous late infection with a high mortality rate. Late infections were responsible for ten deaths that were all caused by atypical pneumonia. The majority of late infections appeared during the first year after liver transplantation. Thereafter, the risk of infection declined significantly.

Rejection episodes after liver transplantation during primary immunosuppression with FK506 or a cyclosporine-based regimen: a controlled, prospective, randomized trial

As part of a European multicenter study to investigate the potency of FK506 in primary immunosuppression after liver transplantation, this comparison with our conventional cyclosporine-based quadruple regimen was carried out as a controlled, prospective, randomized trial. The 121 patients entering the study were randomly assigned to receive immunosuppressive regimens consisting either of FK506 and prednisolone (FK/n = 61) or of cyclosporine, prednisolone, azathioprine, and a 7-day course of rabbit antithymocyte globulin (CsA/n = 60). Rejection was suspected in the case of scant production of light bile or biochemical graft dysfunction, without evidence of vascular, biliary, or infectious complications. A liver biopsy for confirmation of the diagnosis was obtained each time. Initial therapy entailed a 3-d course of high-dose methyl-prednisolone. Steroid resistant rejections were treated with OKT3 monoclonal antibody or, in the group of primary CsA administration, conversion to FK506 as another treatment option. One-year patient (FK: 90.2%; CsA: 96.7%) and graft survival (FK: 88.5%; CsA: 91.7%) did not differ significantly. Overall, 41 patients (33.9%) experienced 50 acute, cellular rejection episodes (RE) [FK: 25 RE in 21 patients (34.4%); CsA: 25 RE in 20 patients (33.3%)]. The histological grading ranged from mild (FK: 14/25; CsA: 8/25) to moderate (FK: 9/25; CsA: 16/25) and severe (FK: 2/25; CsA: 1/25): not significantly different between the two groups. In the CsA-based group, three additional rejection episodes were classified as early chronic (n = 1) and chronic rejection (n = 2).(ABSTRACT TRUNCATED AT 250 WORDS)

[Aorto-intestinal fistula versus angiodysplasia. A difficult differential diagnosis in gastrointestinal bleeding]

A 63-year-old patient had recurrent tarry stools and haemoglobin levels of around 7.0 g/dl. Ten years previously he had undergone an aortobifemoral bypass operation for peripheral vascular disease in the legs. Eight gastroscopies and five coloscopies over ten weeks failed to discover a bleeding source. Although an aorto-intestinal fistula was considered early on, extensive diagnostic tests failed to reveal it. Digital subtraction angiography was suggestive of an angiodysplasia of the terminal ileum, a diagnosis supported when coloscopy during exploratory laparotomy visualized blood trickling from the terminal ileum. As a result of this finding a right hemicolectomy was performed. But recurrent bleedings necessitated relaparotomy which finally revealed a fistula between the ascending duodenum and the proximal bypass graft anastomosis. Nine months after resection of the proximal anastomotic area and interposition of a Dacron prosthesis the patient has been free of symptoms.

[Modified substitution of intracellular cations]

In order to ascertain the effect of modified supplementation of electrolytes and trace metals on intracellular uptake, 75 patients undergoing mitral valve replacement were randomly divided into three groups: group A (n = 25) received potassium and sodium chloride while group B (n = 25) was treated with potassium aspartate; in group C (n = 25), a balanced solution of electrolytes and trace metals (Inzolen) with aspartate as the anion was given. The treatment in the three groups was administered on the basis of frequently measured plasma levels of potassium and sodium. Anesthesia was similar in all patients; cardiac arrest was performed by crossclamping of the aorta using "Bretschneider's cardioplegia" for sodium withdrawal. After removal of the mitral valve, a sample of papillary muscle was obtained and analyzed by atomic absorption for its content of sodium, potassium, magnesium, zinc, and copper (Na, K, Mg, Zn, Cu). Sodium levels in papillary tissue were below the normal range in all groups and without differences depending upon the kind of treatment. Potassium levels in group A, however, (KCl) were markedly below those in groups B and C (aspartates). A similar effect could be observed with respect to tissue levels of Mg, Zn, and Cu. Supplementation of trace metals (group C) had no additional effect on tissue concentrations: there were no significant differences between group B (K aspartate) and group C (K-, Mg-, Zn-, Cu-, Na aspartate). Our results stress the importance of effective treatment of electrolyte and trace metal deficiencies. The present data suggest that the utilization of intracellular cations can particularly be improved by using solutions with aspartate as the anion.