Adjuvant sunitinib following chemoradiotherapy and surgery for locally advanced esophageal cancer: a phase II trial.

The prognosis for locally advanced esophageal cancer is poor despite the use of trimodality therapy. In this phase II study, we report the feasibility, tolerability and efficacy of adjuvant sunitinib. Included were patients with stage IIa, IIB or III cancer of the thoracic esophagus or gastroesophageal junction. Neoadjuvant therapy involved Irinotecan (65 mg/m2 ) + Cisplatin (30 mg/m2 ) on weeks 1 and 2, 4 and 5, 7 and 8 with concurrent radiation (50Gy/25 fractions) on weeks 4-8. Sunitinib was commenced 4-13 weeks after surgery and continued for one year. Sixty-one patients were included in the final analysis, 36 patients commenced adjuvant sunitinib. Fourteen patients discontinued sunitinib due to disease recurrence (39%) within the 12-month period, 12 (33%) discontinued due to toxicity, and 3 (8%) requested cessation of therapy. In the overall population, median survival was 26 months with a 2 and 3-year survival rate of 52% and 35%, respectively. The median survival for the 36 patients treated with sunitinib was 35 months and 2-year survival probability of 68%. In a historical control, a prior phase II study with the same trimodality therapy (n = 43), median survival was 36 months, with a 2-year survival of 67%. Initiation of adjuvant sunitinib is feasible, but poorly tolerated, with no signal of additional benefit over trimodality therapy for locally advanced esophageal cancer.

Cystic echinococcosis: late rupture and complication of a stable pulmonary cyst.

Cystic echinococcosis is observed worldwide. Traditional management includes an invasive surgical approach with adjunctive chemotherapy. It has been suggested that observation alone may be appropriate in asymptomatic individuals with stable cysts. A case involving a 38-year-old Peruvian man with an asymptomatic bronchogenic cyst (suspected to be due to echinococcus, but never definitely diagnosed) is presented. The cyst was first noted in 1998, and was followed for 10 years during which time he remained asymptomatic with minimal radiographic change. One year later, in 2009, he presented with acute rupture of the cyst causing empyema. The patient required thoracotomy, decortication and resection of the ruptured cyst. Final pathology showed Echinococcus organisms. The patient responded well to treatment with albendazole and praziquantel, and became completely asymptomatic within six months. The present case demonstrates that echinococcal cysts may be at risk of spontaneous rupture, even after many years of clinical stability, thus supporting the case for resection of asymptomatic cysts suspected of being echinococcal at the time of diagnosis. In addition, the case illustrates that medical therapy with albendazole and praziquantel, in conjunction with surgical drainage, can be successful in the treatment of echinococcal empyema.

Analysis of explants and causes of mortality during long-term follow-up of the Toronto stentless porcine valve.

UNLABELLED: The long-term status of stentless porcine valves has not yet been defined. METHODS: 447 patients were followed at 6 IDE sites up to 10 years (total follow-up, 2024.3 pt years; mean, 4.5 years): 35% were over 70 years and 41% underwent concomitant coronary artery bypass grafting. RESULTS: 10 patients underwent reoperation for valve explant (0.5%/pt year) because of severe aortic incompetence (AI) from dilatation of the aorta, sinotubular junction or sinus of Valsalva with torn commissures or cusps (8 patients) and endocarditis with abscess and dehiscence (2 patients). Six of 8 patients with late AI had bicuspid native aortic valves (mean age, 39.8 years). Overall freedom from reoperation was 95.2%. Freedom from structural deterioration was 96.1% at 7 years (98.0% for patients >60 years). Of 49 late deaths (2.5%/pt year), 9 were valve related (0.5%/pt year), 10 cardiac related, and 30 because of noncardiac causes. Valve-related deaths were because of endocarditis (3), CVA (1), redo surgery (1), or unknown reasons (4). Noncardiac deaths were due mainly to cancer (19/30). At seven years, freedom from all cause death was 81.8% and freedom from valve-related death 96.9%. CONCLUSIONS: Late mortality after stentless valve replacement has been primarily because of comorbidities present at surgery or developing later. The Toronto stentless porcine valve is associated with a low rate of reoperation and valve-related death.