Purpose: The aim of this study was to review our local experience with diagnosis, staging, and treatment of stage II colon cancer, particularly those classified as high-risk disease. Methods: At Centre Hospitalier Universitaire de Sherbrooke, all patients operated for a non-metastatic colon cancer between 2005 and 2012 and identified as pathological stage II according to the AJCC classification 7th version were included in the study. Retrospective analyses were performed on the diagnostic methods, surgery, perioperative complications, pathology results, and adjuvant chemotherapy. Disease-free survival (DFS) and overall survival (OS) were examined with Kaplan-Meier plots. Results: Two hundred (n=200) patients were identified as pathological stage II, 113 of whom were classified as high-risk disease. Clinical staging which included colonoscopy, thoracic, abdominal, and TEP scans were performed in 88%, 91.5%, 82%, and 17.5% of patients, respectively. Post-operative complications occurred in 39% of patients, the most frequent being infectious (leak and/or abscess) in 43.6% and cardiovascular events in 24.4%. Pathological analysis revealed 87.6%, 8.5%, and 4% of stage IIA, IIB, and IIC tumor, respectively. One or more high-risk criteria were identified in 56.5% of patients and were defined as T4 (12.5%), lymphovascular invasion (43%), less than 12 nodes resected (8.5%), perforation (3%), or obstruction (6%) at presentation. Adjuvant treatment was administered to 18.5% of patients, 81.1% of them being considered high risk. The chemotherapy regimens used were FOLFOX in 51.3%, infusional 5-FU/LV in 21.6%, capecitabine in 24.3%, and capecitabine with oxaliplatin in 2.7%. The median delay between surgery and the first chemotherapy treatment was 62 (22, 135) days. The 5-year OS was 77.5% without benefits in patients receiving adjuvant treatment compared with surgery alone (80.5 vs. 76.9%; p=0.31). The 5-year DFS was 73.8% with no difference in the adjuvant therapy group (81.1% vs. 72.2%; p=0.27). Among the high-risk patients, there was a trend in favor of chemotherapy in the 5-year OS (80.9% vs. 67.8%; p=0.08), while there was none in the 5-year DFS (82.3% vs. 66.3%; p=0.12). Our analyses showed that perforation at presentation and T4 tumors were features associated with poorer overall survival. Conclusion: Our local experience shows that adjuvant chemotherapy in patients with stage II colorectal cancer did not significantly improve DFS or OS, but could possibly benefit those with high-risk disease. The applicability of these results is limited by the fact that this is a retrospective study with a limited number of patients.
Objective The study aimed to estimate the predictive value of midtrimester cervical length (CL) and the optimal cut-off of CL that should be applied with asymptomatic nulliparous women for the prediction of spontaneous preterm birth (sPTB). Study Design This is a prospective cohort study of asymptomatic nulliparous women with a singleton gestation. Participants underwent CL measurement by transvaginal ultrasound between 20 and 24 weeks of gestation. The participants and their health care providers remained blinded to the results of CL measurement. The primary outcomes were sPTB before 35 weeks and sPTB before 37 weeks. Receiver operating characteristics (ROC) curve analyses were performed. Analyses were repeated by using multiples of median (MoM) of CL adjusted for gestational age. Results Of 796 participants, the mean midtrimester CL was 40 ± 6 mm with a 1st, 5th, and 10th percentile of 25, 29, and 32 mm, respectively. ROC curve analyses suggest that a cut-off of 30 mm was the optimal CL to predict sPTB before 35 weeks (area under the ROC curve [AUC]: 0.70, 95% confidence interval [CI]: 0.56–0.85) and before 37 weeks (AUC: 0.70, 95% CI: 0.59–0.80). Midtrimester CL <30 mm could detect 35% of all sPTB before 35 weeks at a false-positive rate of 5% (relative risk: 9.1, 95% CI: 3.5–23.5, p < 0.001). We observed similar results using a cut-off of CL <0.75 MoM adjusted for gestational age. Conclusion A midtrimester CL cut-off of 30 mm (instead of 25 mm), or CL less than 0.75 MoM, should be used to identify nulliparous women at high risk of sPTB. Key Points
Purpose: Prucalopride succinate is an enterokinetic of a new class, the dihydrobenzofurancarboxamide, with high affinity for 5-HT4 receptor. Its main action is to stimulate myenteric neurons to release acetylcholine, calcitonin gene related-peptide, and azote monoxide which result in an increase of intestinal contractility and peristalsis. This medication was proven efficient to treat chronic idiopathic constipation in three randomized-controlled trials. Considering the effects of prucalopride succinate on digestive motility, other utilizations come to mind. However, only one controlled double-blind pilot study of 11 patients with chronic constipation secondary to spinal cord trauma found an increased number of stool and a decreased transit time with prucalopride succinate. Only one case report was found on a 54-yearold man with acute pseudo-obstruction secondary to paraplegia treated with success with prucalopride 2 mg PO die where decompression colonoscopy, neostigmine and Prostigmine® proved inefficient. We encountered a similar case in our institution. A 68-year-old man presented for neoplastic spinal cord compression with progressive lower limb paresis and paresthesias over one week. He was found to suffer from IgA multiple myeloma with plasmacytoma and had emergent surgical decompression of his spinal cord. In the days following his surgery, he developed urinary and fecal retention with an increased abdominal volume and loss of appetite. An Ogilvie syndrome with a 10 cm right colonic distension was diagnosed fifteen days after his admission. At that moment, he was on narcotics for his recent spinal surgery, he was about to receive his third chemotherapy regimen (Velcade®/Decadron®) and was immobilized secondary to his lower limb paresis. He was on docusate 200 mg PO bid and bisacodyl 10 mg IR qd. He resumed partially his Ogilvie syndrome with neostigmine 2 mg IV and was then put on prucalopride succinate 2 mg PO qd for 3 days with incomplete bowel movement and persistent abdominal discomfort. Prucalopride succinate was increased to 4 mg PO qd with addition of Lax-A-Day® 17 g PO qd with satisfactory bowel movement and increased well-being and appetite. He passed stool regularly with resolution of his colonic distension. Ultimately, after a total of 16 days, he regained ambulation and the prucalopride succinate was stopped without recurrence of pseudo-obstruction.
Depuis quelques annees, de nombreuses evolutions ont ete observees dans le traitement adjuvant des cancers coliques. Apres la demonstration de l’utilite du 5FU – levamisole au debut des annees 1990, les standards ont ete le Fufol, puis le LV5FU2. Les recents resultats de l’etude Mosaic demontrent une nouvelle amelioration de la prise en charge avec le Folfox4 qui doit desormais devenir le standard therapeutique : le taux de patients vivants sans rechute a 3 ans est de 78,2 % pour les patients traites par Folfox4, compare a 72,9 % pour les patients traites par LV5FU2 (p = 0,002). Il est recommande de proceder a une chimiotherapie adjuvante pendant 6 mois dans les stades III. Ce traitement est une option dans les stades II, mais l’avantage observe, par exemple dans l’etude Mosaic pour les stades II « graves », est au moins egal a celui obtenu dans les stades III. Les patients âges peuvent etre traites selon les memes modalites que les patients plus jeunes, en se basant sur l’âge physiologique et les contre-indications relatives des pathologies associees. Les etudes a venir vont tâcher de definir la place des nouvelles therapies ciblees en association avec la chimiotherapie conventionnelle dans le traitement adjuvant des cancers coliques. Pour l’instant, les differentes tentatives de selection des patients selon des criteres de biologie moleculaire ne permettent pas encore de mieux preciser les indications de la chimiotherapie adjuvante, mais des etudes prospectives pourront sans doute dans un proche avenir etre d’une reelle aide decisionnelle.
Phlegmonous gastritis is a pyogenic infection affecting the submucosa of the gastric wall. Although rarely diagnosed, it remains a disease with high mortality. We thereby describe the case of a 42-year-old male patient known for psoriatic arthritis on Infliximab who was diagnosed with phlegmonous gastritis secondary to immunosuppressive therapy. The patient had a favourable outcome with a conservative treatment consisting of a 14-day course of broad antibiotherapy.
Introduction: Pancreatic adenocarcinoma is the fourth leading cause of cancer deaths in Canada and mainly affects individuals older than 60 years of age. It is associated with particularly high 1 and 5-year mortality rates of 75% and 94% respectively. Because of its retroperitoneal location, pancreatic cancer follows a relatively silent clinical course and is more often diagnosed at an advanced stage, thereby ruling out the possibility of surgical resection and cure. When faced with a diagnosis of unresectable pancreatic adenocarcinoma, patients may be offered palliative chemotherapy. Unfortunately, a paucity of data exists regarding the use, efficacy and safety profile of chemotherapeutic agents in the elderly population with pancreatic cancer; this specific population being often excluded from randomized trials. With already 1 in 6 Canadians aged older than 65 years old and an aging population, clinicians are bound to be faced with oncologic decisions regarding treatment of those under-represented elderly patients with pancreatic adenocarcinoma. It is therefore imperative to study this population in order to offer adapted and proven treatment protocols and ensure adequate and optimal care. Methods: This is a retrospective observational study of all patients aged older than 75 years old with a diagnosis of unresectable or metastatic pancreatic cancer at the CHUS between June 2005 and June 2015. Data was retrieved using the local patient database program Ariane. Results: During the study period, 186 patients were included according to the entry criteria. Median age at diagnosis was 82 years old with a slight female gender predominance (52% vs 48%). Location of the primary tumor was in the head of the pancreas in 46% of cases, and evenly distributed between the pancreatic body and tail. Diagnosis was made by the general practitioners or gastroenterologists in 73.4% of cases. High blood pressure, diabetes mellitus and coronary atherosclerosis were the most frequently encountered comorbidities. Other biochemistry parameters at diagnosis suggested a more fragile population; median albumin level of 32 g/L, median creatinine value of 155 μmol/L and minor anemia (median = 11.7 g/dL). Among the 96 patients who were offered chemotherapy, only 10 accepted this palliative treatment. ECOG status was unfortunately far from uniformly documented, although among the 10 patients treated, all had either ECOG 0 or 1 scores. Nine received Gemcitabine as first line whereas one patient was treated with Folfirinox. Seven completed the treatment with the standard regimen dosage for each cycle. Patients received a median of 5 cycles and end of treatment was dictated by severe asthenia complicating treatment. Only 2 patients, non-responders, received second-line agents (5FU/LV) that were subsequently stopped, again for non-response. Conclusion: Results of this unicentric observational retrospective study suggest an overall diminished clinical performance status in elderly patients (>75 years old) diagnosed with unresectable or metastatic pancreatic cancer when compared to their younger counterparts. Due to our small sample size, it remains difficult to draw conclusions on ideal patient selection criterion and palliative treatment for advanced pancreatic cancer in the elderly. The present study does, however, underline the dire need for further studies on the matter.
e15555 Background: MVASI is a biosimilar to the reference product, bevacizumab, and is the first biosimilar approved by Health Canada for the first-line (1L) treatment of metastatic colorectal cancer (mCRC). This study addresses the limited real-world evidence by describing the safety and effectiveness of MVASI as 1L therapy in mCRC. Methods: Retrospective data were collected in two waves of sites across Canada, at least 1 year (wave 1) or 2 years (wave 2) after commercial availability of MVASI at each site. Adult patients treated with ≥ 1 MVASI cycles as their 1L therapy for mCRC were included. Baseline demographic and clinical characteristics were collected 6 months prior to MVASI initiation (index date). Medical history, adjuvant treatment, and CRC diagnosis were collected within 5 years of pre-index date. Outcomes were gathered between index and chart review dates. Results: Among the 75 patients in wave 1, 36 (48.0%) were male and the median age was 62 years. Of the 164 patients in wave 2, 98 (59.8%) were male and the median age was 67 years. Most patients in wave 1 (42/69; 60.9%) and wave 2 (87/141; 61.7%) had a RAS mutation. The median time from mCRC diagnosis to MVASI initiation among wave 1 and 2 patients was 3.1 (IQR [2.1, 4.2]) and 2.3 months (IQR [1.6, 3.7]), respectively. At least one safety event of interest (EOI) was recorded for 26/75 (34.7%) wave 1 and 70/164 (42.7%) wave 2 patients (Table 1). The median progression free survival (PFS) for wave 1 and 2 patients were 9.47 and 21.38 months, respectively. Median overall survival (OS) for wave 1 patients was not estimable and was 26.45 months for wave 2 patients. Conclusions: In this real-world study, mCRC patients treated with 1L MVASI were generally representative of the Canadian mCRC population treated with 1L bevacizumab. Compared with clinical trials of MVASI and reference bevacizumab, the EOI profile and the OS data are similar, but lower rates of individual EOIs are observed in this real-world setting. The shorter PFS observed in wave 1 may be due to higher rates of comorbidities at baseline and longer time from mCRC diagnosis to index. [Table: see text]
Purpose: Gastric cancer has a decreasing incidence in Canada although it remained the 9th cause of cancer death as of 2011. The optimal treatment approach remains unknown and challenge remains in improving survival due to advanced disease at presentation. The NCCN guidelines recommend surgical resection with perioperative fluoropyrimidine-based chemotherapy for stage T2 or higher disease. The aim of this study was to review our local experience with diagnosis, staging and treatment of gastric cancer. Methods: A total of 65 patients operated for gastric or esophagogastric junction adenocarcinoma at Centre Hospitalier Universitaire de Sherbrooke between year 2000 and 2012 were identified. Among them, information related to diagnosis, surgery and complications, pathology results, chemotherapy treatment and overall outcome were retrospectively analyzed. Overall survival was estimated with Kaplan-Meier plots. Results: The mean age of patients was 66.7 ± 11.19 years with 64.6% male and 35.4% female. The most common presentation was dysphagia (33.8%), epigastric pain (26.1%) & occult bleeding (21.5%). For staging purpose, abdominal CT was performed in 89.2% of patients, thoracic CT in 36.9%, endoscopic ultrasound in 16.9% and PET CT in 33.8%. 13.8%, 26.1%, 43% had respectively well, moderately or poorly differentiated adenocarcinoma; 58.8% of them were signet ring cell type. Poorly differentiated neoplasia had worse survival at 5 years (76.9% vs 47%, p = 0.02) and the overall 5-year survival was not affected by the signet ring cell histology type (66.3 vs 48.3% p =0.2). Final pathology staging was 30.7% stage I disease, 29.2% stage II, 30.7% stage III and 7.7% stage IV. 46.2% had perioperative treatment; 50% of them had chemoradiotherapy according to Macdonald protocol, 10% perioperative chemotherapy according to MAGIC protocol and 20% had adjuvant chemotherapy alone. During follow-up, 40% had either locoregional or distant relapse; 88.5% of them died subsequently. Overall survival was 59.7 at 5 years and 41.3% at 10 years. In this retrospective study, there was a trend toward survival benefit with chemotherapy at 24 months (p=0.081) but the difference disappeared at 30 months. We could not demonstrate any benefit of adjuvant treatment according to the signet cell subtype vs non signet ring cell subtypes. Conclusion: Our experience shows high survival results which are probably explained by the high percentage of stage II & III cancer and the number of patients included. Diagnosis work-up needs to be improved in order to identify patients with best surgical resectability and medical treatment. More research needs to be done with respect to perioperative regimens to improve survival.
