Adjuvant hepatic arterial infusion pump chemotherapy and resection versus resection alone in patients with low-risk resectable colorectal liver metastases - the multicenter randomized controlled PUMP trial.

BACKGROUND: Recurrences are reported in 70% of all patients after resection of colorectal liver metastases (CRLM), in which half are confined to the liver. Adjuvant hepatic arterial infusion pump (HAIP) chemotherapy aims to reduce the risk of intrahepatic recurrence. A large retrospective propensity score analysis demonstrated that HAIP chemotherapy is particularly effective in patients with low-risk oncological features. The aim of this randomized controlled trial (RCT) --the PUMP trial-- is to investigate the efficacy of adjuvant HAIP chemotherapy in low-risk patients with resectable CRLM. METHODS: This is an open label multicenter RCT. A total of 230 patients with resectable CRLM without extrahepatic disease will be included. Only patients with a clinical risk score (CRS) of 0 to 2 are eligible, meaning: patients are allowed to have no more than two out of five poor prognostic factors (disease-free interval less than 12 months, node-positive colorectal cancer, more than 1 CRLM, largest CRLM more than 5 cm in diameter, serum Carcinoembryonic Antigen above 200 µg/L). Patients randomized to arm A undergo complete resection of CRLM without any adjuvant treatment, which is the standard of care in the Netherlands. Patients in arm B receive an implantable pump at the time of CRLM resection and start adjuvant HAIP chemotherapy 4-12 weeks after surgery, with 6 cycles of floxuridine scheduled. The primary endpoint is progression-free survival (PFS). Secondary endpoints include overall survival, hepatic PFS, safety, quality of life, and cost-effectiveness. Pharmacokinetics of intra-arterial administration of floxuridine will be investigated as well as predictive biomarkers for the efficacy of HAIP chemotherapy. In a side study, the accuracy of CT angiography will be compared to radionuclide scintigraphy to detect extrahepatic perfusion. We hypothesize that adjuvant HAIP chemotherapy leads to improved survival, improved quality of life, and a reduction of costs, compared to resection alone. DISCUSSION: If this PUMP trial demonstrates that adjuvant HAIP chemotherapy improves survival in low-risk patients, this treatment approach may be implemented in the standard of care of patients with resected CRLM since adjuvant systemic chemotherapy alone has not improved survival. TRIAL REGISTRATION: The PUMP trial is registered in the Netherlands Trial Register (NTR), number: 7493 . Date of registration September 23, 2018.

Preoperative [18F] FDG-PET after chemotherapy in locally advanced breast cancer: prognostic value as compared with histopathology.

BACKGROUND: Established prognosis-based criteria determine the need for further treatment after primary surgery for breast cancer. Such criteria are lacking after neo-adjuvant chemotherapy. We determine the prognostic value of preoperative [(18)F]-2-fluoro-2-deoxy-D-glucose-positron emission tomography ((18)FDG-PET) after chemotherapy in locally advanced breast cancer (LABC), both as independent indicator and as add-on to postoperative histopathology. PATIENTS AND METHODS: Preoperative PET was carried out in 40 LABC patients. Two expert readers assessed residual (18)FDG uptake in the primary tumor. At histopathological examination of the surgical specimen, chemotherapy response was graded using the Honkoop criteria. Cox proportional hazards analysis was used to determine prognostic relevance of PET and histopathology. RESULTS: Median follow-up was 60 months (range 15-94), during which 13 patients had recurrent disease, eight of whom died. (18)FDG uptake in the primary tumor was inversely related with disease-free survival (DFS) [hazard ratio (HR) 4.09; 95% confidence interval (CI) 1.26-13.31; P = 0.02] and this was superior to histopathology (HR 2.52; 95% CI 0.77-8.23; P = 0.13). Observer agreement of PET was excellent (intraclass correlation coefficient 0.88). Multivariate Cox regression revealed no added value of histopathology versus PET results. CONCLUSION: (18)FDG uptake in the primary tumor at PET was inversely associated with DFS and may help to guide adjuvant therapy.

Colocalization of VIP with AVP in neurons of the human paraventricular, supraoptic and suprachiasmatic nucleus.

Aim of this study was to investigate, with the aid of a recently developed immunofluorescence technique, cellular colocalization of vasoactive intestinal peptide (VIP) with arginine-vasopressin (AVP) in the paraventricular nucleus (PVN), the supraoptic nucleus (SON) and the suprachiasmatic nucleus (SCN) of the human hypothalamus. To this end, six hypothalami resected from patients who had died suddenly served as material of research. After formaldehyde fixation and subsequent storage in 30% sucrose, 25-microm thick cryosections were cut of one half of each hypothalamus. These sections were double-immunolabeled with primary antibodies against AVP and VIP followed by fluorophore-conjugated secondary antibodies. Autofluorescence, mainly caused by lipofuscin granules in neurons and glial cells, was blocked by a specially developed procedure consisting of incubating the immunolabeled sections in a Sudan Black B solution. Quantitative analysis with a confocal laser scanning microscope showed that of all stained cellular profiles the percentages of profiles immunoreactive exclusively for AVP or VIP or for both neuropeptides (colocalization) were for the SCN approximately 76.5%, 19.6% and 3.9%, for the SON 97.7%, 0.2% and 2. 1% and for the PVN 93.2%, 1.6% and 5.2%, respectively. These data illustrate that colocalization between AVP and VIP is not only present in neurons of the PVN and SON, but also in neurons of the SCN. This unexpected finding illustrates that the human SCN may also use a highly differentiated language to transmit its circadian signal to the rest of the brain.

Double immunolabeling of neuropeptides in the human hypothalamus as analyzed by confocal laser scanning fluorescence microscopy.

The main goal of this study was to develop a better light microscopic procedure for quantitative study of the cellular co-localization of neuropeptides in adult human brain tissue. To reach this goal, we opted for a method (proved to be optimal on rat brain) in which sections were double immunolabeled with two different fluorophore-conjugated secondary antibodies and analyzed with a confocal laser scanning fluorescence microscope. One of our main problems faced was a strong autofluorescence of the sections, mainly caused by lipofuscin granules normally present in adult human brain tissue, which made any analysis of specific fluorescence impossible. This problem could be solved by staining the sections after immunolabeling with the dye Sudan Black B, which completely blocked this autofluorescence. The complete optimized procedure that we eventually developed can be summarized as follows. After a relatively short fixation time (6-14 days) in 4% freshly depolymerized paraformaldehyde, the resected brain tissue can best be stored in a 30% sucrose solution supplemented with 0.05% NaN3 at 4C. Stored under these conditions, cryosections from the tissue still reveal good histology and allow successful immunocytochemical staining after a period of 6 months. Double immunolabeling is done by incubating cryo- or paraffin sections in a mixture of two primary antibodies directed against the targeted antigens, followed by incubation with two different fluorophore-conjugated secondary antibodies. Amplification with a biotinylated secondary antibody followed by fluorophore-conjugated streptavidin is possible. Finally, the sections are stained with Sudan Black B, mounted in plain 80% Tris-buffered glycerol, and studied by confocal laser scanning fluorescence microscopy. Sections processed in this way are well suited for qualitative and quantitative analyses of co-localized neuropeptides in human brain tissue.