Upfront FOLFOXIRI+bevacizumab followed by fluoropyrimidin and bevacizumab maintenance in patients with molecularly unselected metastatic colorectal cancer

BACKGROUND

The addition of bevacizumab (BEV) to standard doublet chemotherapy improves outcomes compared with chemotherapy alone in patients with metastatic colorectal cancer (mCRC). The OPAL study examined the effect of BEV+FOLFOXIRI followed by 5FU/LV and BEV maintenance on progression-free survival (PFS) in patients with previously untreated unresectable mCRC.

METHODS

Eligible patients had histologically confirmed mCRC, ECOG performance status ⩽1 and were 18-70 years old. Patients received up to 12 cycles of FOLFOXIRI+BEV q2w (induction phase) followed by up to ⩽40 cycles of 5FU/LV+BEV q2w (maintenance phase). Median PFS was the primary end point; secondary end points included response, OS, secondary resection rate, safety and prognostic value of pharmacogenetic profiling.

RESULTS

Ninety-seven patients were enrolled. Of these, 90 received study medication and formed the safety population: 64 males; median age 58 (range 28-71) years; ECOG performance status 0/1 in 54%/46% patients; and liver only disease in 35 patients. Relative dose intensities were 79-85% for all four drugs. The incidence of adverse events (AEs) was as previously reported and there were no new safety signals. In total, 87 serious AEs occurred in 39 patients (43%). Median PFS was 11.1 months (95% CI 9.4-12.0) and did thus not meet the primary objective of 12 months. Median OS was 32.2 months (95% CI 22.6-36.9). Fifty-two patients were pharmacogenetically profiled.

CONCLUSIONS

FOLFOXIRI+BEV was feasible in this molecularly unselected mCRC patient population, showing a high efficacy in terms of survival, overall response and secondary resection rate. Pharmacogenomic profiling revealed no clinically relevant marker.

Locally ablative treatment of breast cancer liver metastases: identification of factors influencing survival (the Mammary Cancer Microtherapy and Interventional Approaches (MAMMA MIA) study)

BACKGROUND

Liver metastases from breast cancer (LMBC) are typically considered to indicate systemic disease spread and patients are most often offered systemic palliative treatment only. However, retrospective studies suggest that some patients may have improved survival with local treatment of their liver metastases compared to systemic therapy alone. In the absence of randomized trials, it is important to identify patient characteristics indicating that benefit from local treatment can be expected.

METHODS

59 patients undergoing radiofrequency ablation (RFA), interstitial brachytherapy (BT), or radioembolization (RE) of LMBC as a salvage treatment were studied. Potential factors influencing survival were analyzed in a multivariate Cox model. For factors identified to have an independent survival impact, Kaplan-Meier analysis and comparison of overall survival (OS) using the log-rank test was performed.

RESULTS

Median OS following local interventional treatment was 21.9 months. Considering only factors evaluable at treatment initiation, maximum diameter of liver metastases (≥3.9 cm; HR: 3.1), liver volume (≥ 1376 mL; HR: 2.3), and history of prior chemotherapy (≥ 3 lines of treatment; HR: 2.5-2.6) showed an independent survival impact. When follow-up data were included in the analysis, significant factors were maximum diameter of liver metastases (≥ 3.9 cm; HR: 3.1), control of LMBC during follow-up (HR: 0.29), and objective response as best overall response (HR: 0.21). Neither the presence of any extrahepatic metastases nor presence of bone metastases only had a significant survival impact. Median OS was 38.7 vs. 16.1 months in patients with metastases < vs. ≥ 3.9 cm, 36.6 vs. 10.2 months for patients having objective response vs. stable/progressive disease, and 38.5 vs. 14.2 months for patients having controlled vs. non-controlled disease at follow-up.

CONCLUSION

Local control of LMBC confers a survival benefit and local interventional treatment for LMBC should be studied in a randomized trial. Patients with small metastases and limited history of systemic LMBC treatment are most likely to benefit from local approaches. Limited extrahepatic disease should not lead to exclusion from a randomized study and should not be a contraindication for local LMBC treatment as long as no randomized data are available.

Left-liver hypertrophy after therapeutic right-liver radioembolization is substantial but less than after portal vein embolization

In patients with liver malignancies potentially amenable to curative extended right hepatectomy but insufficient size of the future liver remnant (FLR), portal vein embolization (PVE) of the tumor-bearing liver is used to induce contralateral liver hypertrophy but leaves the tumor untreated. Radioembolization (RE) treats the tumor in the embolized lobe along with contralateral hypertrophy induction. We performed a matched-pair analysis to compare the capacity for hypertrophy induction of these two modalities. Patients with right-hepatic secondary liver malignancies with no or negligible left-hepatic tumor involvement who were treated by right-lobar PVE (n = 141) or RE (n = 35) at two centers were matched for criteria known to influence liver regeneration following PVE: 1) baseline FLR/Total liver volume ratio (<25 versus ≥ 25%); 2) prior platinum-containing systemic chemotherapy; 3) embolization of segments 5-8 versus 4-8; and 4) baseline platelet count (<200 versus ≥ 200 Gpt/L).The primary endpoint was relative change in FLR volume from baseline to follow-up. Twenty-six matched pairs were identified. FLR volume increase from baseline to follow-up (median 33 [24-56] days after PVE or 46 [27-79] days after RE) was significant in both groups but PVE produced significantly more FLR hypertrophy than RE (61.5 versus 29%, P < 0.001). Time between treatment and follow-up was not correlated with the degree of contralateral hypertrophy achieved in both groups. Although group differences in patient history and treatment setting were present and some bias cannot be excluded, this was minimized by the matched-pair design, as remaining group differences after matching were found to have no significant influence on contralateral hypertrophy development.

CONCLUSION

PVE induces significantly more contralateral hypertrophy than RE with therapeutic (nonlobectomy) doses. However, contralateral hypertrophy induced by RE is substantial and RE minimizes the risk of tumor progression in the treated lobe, possibly making it a suitable modality for selected patients.

[What do general, abdominal and vascular surgeons need to know on plastic surgery - aspects of plastic surgery in the field of general, abdominal and vascular surgery]

There is overlap between general, abdominal and vascular surgery on one hand and plastic surgery on the other hand, e.g., in hernia surgery, in particular, recurrent hernia, reconstruction of the abdominal wall or defect closure after abdominal or vascular surgery. Bariatric operations involve both special fields too. Plastic surgeons sometimes use skin and muscle compartments of the abdominal wall for reconstruction at other regions of the body. This article aims to i) give an overview about functional, anatomic and clinical aspects as well as the potential of surgical interventions in plastic surgery. General/abdominal/vascular surgeons can benefit from this in their surgical planning and competent execution of their own surgical interventions with limited morbidity/lethality and an optimal, in particular, functional as well as aesthetic outcome, ii) support the interdisciplinary work of general/abdominal/vascular and plastic surgery, and iii) provide a better understanding of plastic surgery and its profile of surgical interventions and options.

Factors influencing the quality of total mesorectal excision

BACKGROUND

Total mesorectal excision (TME) has become the standard of care for rectal cancer. Incomplete TME may lead to local recurrence.

METHODS

Data from the multicentre observational German Quality Assurance in Rectal Cancer Trial were used. Patients undergoing low anterior resection for rectal cancer between 1 January 2005 and 31 December 2009 were included. Multivariable analysis using a stepwise logistic regression model was performed to identify predictors of suboptimal TME.

RESULTS

From a total of 6179 patients, complete data sets for 4606 patients were available for analysis. Pathological tumour category higher than T2 (pT3 versus pT1/2: odds ratio (OR) 1.22, 95 per cent confidence interval 1.01 to 1.47), tumour distance from the anal verge less than 8 cm (OR 1.27, 1.05 to 1.53), advanced age (65-80 years: OR 1.25, 1.03 to 1.52; over 80 years: OR 1.60, 1.15 to 2.22), presence of intraoperative complications (OR 1.63, 1.15 to 2.30), monopolar dissection technique (OR 1.43, 1.14 to 1.79) and low case volume (fewer than 20 procedures per year) of the operating surgeon (OR 1.20, 1.06 to 1.36) were independently associated with moderate or poor TME quality.

CONCLUSION

TME quality was influenced by patient- and treatment-related factors.

Prevention of intraprocedural puncture site bleeding during arterial port implantation by use of a suture-mediated arterial closure system: a prospective randomized trial

PURPOSE

To investigate a modified technique for arterial port placement that uses a suture-mediated closure system with the aim to reduce delays caused by intraprocedural oozing around the catheter.

MATERIALS AND METHODS

Forty consecutive patients (age, 63.9 y ± 11.8) stratified for regional arterial infusion chemotherapy were prospectively randomized to undergo conventional or modified port implantation. Time for device placement, total procedure time, number of catheters, size of largest and final catheters placed, duration of bleeding from puncture site, procedural delays, and time until hemostasis was achieved were recorded.

RESULTS

Time for device placement was 3.7 minutes ± 1.1, with no complications encountered. Total procedure times were 133.0 minutes ± 62.8 for conventional port implantation and 100.0 minutes ± 49.5 for modified implantation (P = .13). No differences were found in the number of catheters or size of largest or final catheter used. Duration of groin bleeding necessitating manual compression was 21.8 minutes ± 24.4 for conventional port implantation, resulting in a mean procedural delay of 6.2 minutes ± 7.0. Hemostasis was achieved after a mean of 17.1 minutes ± 20.9. Groin hematoma was observed in three patients. In contrast, with the modified technique, mean duration of oozing and intraprocedural delays were only 0.2 minutes ± 0.6 and 0.1 minutes ± 0.5, respectively (both P < .0001 vs conventional technique). Hemostasis was achieved within 3.2 minutes ± 4.1 (P < .0001), with no cases of hematoma found.

CONCLUSIONS

Use of a suture-mediated closure system facilitated arterial port implantation by effective prevention of groin bleeding while allowing the use of a sheath.

[Palliative chemotherapy for colorectal cancer--current state, significance, trends]

BACKGROUND

There are a number of effective substances available for palliative treatment of colorectal cancer, contributing to a considerable extension of the median survival time either purely medically or by increasing the chance of secondary resectability through improved effectiveness of the administered drugs. PATIENTS / MATERIAL: Defining treatment depending on predominant patient characteristics remains crucial for any therapeutic success. This requires interdisciplinary co-ordination within tumour boards.

METHODS

In aggressive tumours a therapeutic approach inducing high response rates is favoured, usually including a triple or quadruple combination incl. antibodies. In cases of slow tumour progress and limited patient profile, a sequence of chemotherapy is chosen. Implementing and integrating locally ablative modes of therapy into the treatment strategy can increase the effectiveness additionally. In a best case scenario additional systemic side effects can be avoided resulting in a not insignificant benefit in quality of life.

RESULTS

Further genotyping beyond the K-RAS state is necessary to make predictive and prognostic statements concerning the drugs applied and to avoid ineffectiveness.

CONCLUSION

Considerable progress has been achieved in the medical therapy for metastasised colorectal cancer. The targeted application of already available as well as recently developed substances requires further evaluation by appropriate studies.

Surgical practices for malignant left colonic obstruction in Germany

AIM

Data from the multicentric observation study Kolon/Rektum-Karzinome (Primärtumor) (primary colorectal carcinoma) are adduced to assess the status of surgical treatment of this condition in Germany and to compare different operative approaches in the emergency treatment of obstructive left-sided colon cancer, especially diversion (Hartmann's procedure) and primary anastomosis.

PATIENTS AND METHODS

Out of 15,911 patients with cancer of the left colon, recorded between 01.01.2000 and 31.12.2004, a total of 743 patients underwent emergency surgery for an obstructive tumour, performed as a radical resection. These patients were compared in respect of their risk profile and postoperative result.

RESULTS

In 57.9% (n=430) a one-stage operation (Group I), in 11.7% (n=87) a primary anastomosis with protective stoma (Group II), and in 30.4% (n=226), Hartmann's procedure (Group III) was performed. In Group III more patients were male, overweight and multimorbid, and more had advanced-stage tumours. The morbidity and hospital mortality (overall hospital mortality, 7.7%; n=57) did not differ significantly between the groups. The insertion of a protective stoma did not affect the rate of anastomotic insufficiency (Group I, 7%; Group II, 8.0%).

CONCLUSIONS

Primary anastomosis for emergency left colon carcinoma obstruction should only be regarded as indicated in cases where the risk profile is favourable. Our results suggest that in advanced obstruction and in high-risk cases Hartmann's procedure should be used. A protective stoma did not appear to confer any advantage.

[Multimodal treatment of colon cancer?]

Surgical therapy is still the basis of therapy of patients with colon carcinoma. Multimodal therapeutical concepts are presently applied as a therapeutical standard in the adjuvant therapy and increasingly in the systemic therapy of patients with primarily inoperable metastases of the liver to reach a secondary operability. Interdisciplinary multimodal therapeutical concepts are even accepted within the therapy of metastasized colon carcinomas. There are still unanswered questions regarding sequences of palliative systemic therapies and their combinations with local ablative methods.