Endoscopic full-thickness resection of polyps involving the appendiceal orifice: a multicenter international experience.

BACKGROUND: Endoscopic resection of lesions involving the appendiceal orifice remains a challenge. We aimed to report outcomes with the full-thickness resection device (FTRD) for the resection of appendiceal lesions and identify factors associated with the occurrence of appendicitis. METHODS: This was a retrospective study at 18 tertiary-care centers (USA 12, Canada 1, Europe 5) between November 2016 and August 2020. Consecutive patients who underwent resection of an appendiceal orifice lesion using the FTRD were included. The primary outcome was the rate of R0 resection in neoplastic lesions, defined as negative lateral and deep margins on post-resection histologic evaluation. Secondary outcomes included the rates of: technical success (en bloc resection), clinical success (technical success without need for further surgical intervention), post-resection appendicitis, and polyp recurrence. RESULTS: 66 patients (32 women; mean age 64) underwent resection of colonic lesions involving the appendiceal orifice (mean [standard deviation] size, 14.5 (6.2) mm), with 40 (61 %) being deep, extending into the appendiceal lumen. Technical success was achieved in 59/66 patients (89 %), of which, 56 were found to be neoplastic lesions on post-resection pathology. Clinical success was achieved in 53/66 (80 %). R0 resection was achieved in 52/56 (93 %). Of the 58 patients in whom EFTR was completed who had no prior history of appendectomy, appendicitis was reported in 10 (17 %), with six (60 %) requiring surgical appendectomy. Follow-up colonoscopy was completed in 41 patients, with evidence of recurrence in five (12 %). CONCLUSIONS: The FTRD is a promising non-surgical alternative for resecting appendiceal lesions, but appendicitis occurs in 1/6 cases.

Factors influencing the accuracy for tissue classification in multi spectral in-vivo endoscopy for the upper gastro-internal tract.

Hyper spectral imaging is a possible way for disease detection. However, for carcinoma detection most of the results are ex-vivo. However, in-vivo results of endoscopic studies still show fairly low accuracies in contrast to the good results of many ex-vivo studies. To overcome this problem and to provide a reasonable explanation, Monte-Carlo simulations of photon trajectories are proposed as a tool to generate multi spectral images including inter patient variations to simulate 40 patients. Furthermore, these simulations have the huge advantage that the position of the carcinoma is known. Due to this, the effect of mislabelled data can be studied. As shown in this study, a percentage of 30-35% of mislabelled data might lead to significant decrease of the accuracy from around 90% to around 70-75%. Therefore, the main focus of hyper spectral imaging has to be the exact characterization of the training data in the future.

Full-thickness resection of neuroendocrine tumors in the rectum.

BACKGROUND: Rectal neuroendocrine tumors (NETs) are subepithelial tumors with potential for malignancy. Depending on tumor characteristics, endoscopic or surgical resection is recommended. However, the optimal endoscopic approach is not defined. This is the first larger study evaluating endoscopic full-thickness resection (EFTR) of rectal NETs. METHODS: For resection, the full-thickness resection device (FTRD) was used. A registry was created as part of post-market clinical follow-up. All cases of rectal NETs in the registry were analyzed retrospectively. RESULTS: 31 German centers entered data of 501 FTRD procedures and 40 cases of rectal NETs were identified. The median lesion size was 8 mm. All lesions could be resected using FTRD. The median procedure time was 18.5 minutes. Resection was macroscopically and histologically complete in all cases. Full-thickness resection was achieved in 95 %. No major adverse events occurred. Endoscopic follow-up showed no evidence of residual or recurrent tumor. CONCLUSION: EFTR is safe and effective for resection of smaller rectal NETs. Prospective comparative trials are needed to define the role of EFTR of rectal NETs.

Spectral Spatial Variation.

Automatic carcinoma detection from hyper/multi spectral images is of essential importance due to the fact that these images cannot be presented directly to the clinician. However, standard approaches for carcinoma detection use hundreds or even thousands of features. This would cost a high amount of RAM (random access memory) for a pixel wise analysis and would slow down the classification or make it even impossible on standard PCs. To overcome this, strong features are required. We propose that the spectral-spatial-variation (SSV) is one of these strong features. SSV is the residuum of the three dimensional hyper spectral data cube minus its approximation with a fitting in a small volume of the 3D image. By using it, the classification results of carcinoma detection in the stomach with multi spectral imaging will be increase significantly compared to not using the SSV. In some cases, the AUC can be even as high as by the usage of 72 spatial features.

Perceived distress, personality characteristics, coping strategies and psychosocial impairments in a national German multicenter cohort of patients with Crohn's disease and ulcerative colitis.

BACKGROUND AND AIMS: This study examined differences in personality, psychological distress, and stress coping in inflammatory bowel disease (IBD) depending on type of disease and disease activity. We compared patients suffering from Crohn's disease (CD) and ulcerative colitis (UC) with controls. While the literature is replete with distinctive features of the pathogenesis of IBD, the specific differences in psychological impairments are not well studied. METHODS: In this German national multicenter study, participants were recruited from 32 centers. Two hundred ninety-seven questionnaires were included, delivering vast information on disease status and psychological well-being based on validated instruments with a total of 285 variables. RESULTS: CD patients were more affected by psychological impairments than patients suffering from UC or controls. Importantly, patients with active CD scored higher in neuroticism (p < 0.01), psychological distress (p < 0.001) and maladaptive stress coping (escape, p = 0.03; rumination, p < 0.03), but less need for social support (p = 0.001) than controls. In contrast, patients suffering from active UC showed psychological distress (p < 0.04) and maladaptive coping (avoidance, p < 0.03; escape, p = 0.01). Patients in remission seemed to be less affected. In particular, patients with UC in remission were not inflicted by psychological impairments. The group of CD patients in remission however, showed insecurity (p < 0.01) and paranoid ideation (p = 0.04). CONCLUSIONS: We identified specific aspects of psychological impairment in IBD depending on disease and disease activity. Our results underscore the need for psychological support and treatment particularly in active CD.

Investigation of random lasing as a feedback mechanism for tissue differentiation during laser surgery.

Laser surgery provides clean, fast and accurate cutting of tissue. However, it is difficult to detect what kind of tissue is being cut. Therefore, a wrong cut may lead to iatrogenic damage of structures. A feedback system should automatically stop the cutting process when a nerve is reached or accidentally being cut to prevent its damage. This could increase the applicability and safety of using a laser scalpel in surgical procedures. In this study, random lasing (RL) is used to differentiate between skin, fat, muscle and nerve tissue. Among these tissue types, a special emphasis is made on the differentiation of nerve from the rest of the tissues, especially fat since nerve is covered by a fatty layer. The differentiation is done for ex-vivo tissues of a pig animal model. The results show that random lasing can be used to differentiate these tissue types also under room light conditions in open air.

The impact of hospitalization on the performance of capsule endoscopy (CE).

BACKGROUND: For proper evaluation of capsule endoscopy (CE), a complete examination is necessary. AIM: We evaluated risk factors of an incomplete CE with focus on patient hospitalization. METHODS: We retrospectively evaluated 161 consecutive patients who underwent CE between 01.07.2013 and 13.03.2016. Main indications were active bleeding, iron deficiency anemia (IDA), inflammatory bowel disease (IBD), abdominal pain, and familial adenomatous polyposis (FAP). RESULTS: We report the results of 103 in-patients and 56 out-patients. Eighty-two patients were male, average age was 58.9 years (range 18-90). Indications for CE were active bleeding (103 patients), IDA and IBD (16 patients), and FAP, abdominal pain and others (eight examinations each). All FAP patients were out-patients, but showed the longest small bowel transit time (SBTT) of 443.6min (p=0.0001). The shortest SBTT was found in out-patients without FAP (267.5min, p<0.05). In the in-patient group, nine endoscopies did not record the entire small bowel (8.7%) due to battery depletion, compared with only one incomplete examination in the out-patients (1.8%, p=0.036). We found pathologic lesions in the last 30min of the SBTT in 43 patients, and this indicates the necessity for complete examination. Thirteen of these 43 patients showed major lesions such as ulcers or angiodysplasia in this last region alone. CONCLUSION: In-patients might require special treatment to ensure complete examination, since a considerable amount of pathologies can only be found in the ileum.

The Application of Hemospray in Gastrointestinal Bleeding during Emergency Endoscopy.

Introduction. Gastrointestinal bleeding represents the main indication for emergency endoscopy (EE). Lately, several hemostatic powders have been released to facilitate EE. Methods. We evaluated all EE in which Hemospray was used as primary or salvage therapy, with regard to short- and long-term hemostasis and complications. Results. We conducted 677 EE in 474 patients (488 examinations in 344 patients were upper GI endoscopies). Hemospray was applied during 35 examinations in 27 patients (19 males), 33 during upper and 2 during lower endoscopy. It was used after previous treatment in 21 examinations (60%) and in 14 (40%) as salvage therapy. Short-term success was reached in 34 of 35 applications (97.1%), while long-term success occurred in 23 applications (65.7%). Similar long-term results were found after primary application (64,3%) or salvage therapy (66,7%). Rebleeding was found in malignant and extended ulcers. One major adverse event (2.8%) occurred with gastric perforation after Hemospray application. Discussion. Hemospray achieved short-term hemostasis in virtually all cases. The long-term effect is mainly determined by the type of bleeding source, but not whether it was applied as first line or salvage therapy. But, even in the failures, patients had benefit from hemodynamic stabilization and consecutive interventions in optimized conditions.

Computed Tomography-Guided Percutaneous Gastrostomy/Jejunostomy for Feeding and Decompression.

BACKGROUND: An effective method for long-term enteral feeding or stomach decompression is the use of a percutaneous gastrostomy (PEG) or sometimes jejunostomy (PEJ). Under certain circumstances (eg, inadequate transillumination), endoscopic placement of PEG/PEJ tubes is impossible. In these cases, computed tomography (CT)-guided PEG/PEJ may represent an alternative technique. In this study, we evaluate indications, results, and complications of CT-guided PEG/PEJ. MATERIALS AND METHODS: A total of 102 consecutive referred patients were enrolled in the study. Patients came to the endoscopy unit of our department to undergo a CT-guided PEG/PEJ for long-term intragastric/intrajejunal feeding (n = 57) or decompression (n = 45). The majority (n = 98) received a pull-through PEG/PEJ with simultaneous gastroscopy/jejunoscopy. Dose length product and the effective dose for every patient were calculated. RESULTS: PEG/PEJ tube placement was successful in 87.3% (89 of 102). Feeding PEG/PEJ tube placement was successfully completed in 91.2% (52 of 57); decompressive PEG/PEJ tube placement was likewise successfully completed in 82.2% (37 of 45). No procedure-related mortality was observed. Minor complications (eg, tube dysfunction, local bleeding, minimal leakage, local skin infection) were observed in 13 patients. The complication rate was similar between the feeding and decompression groups ( P = .9). CONCLUSIONS: CT-guided PEG/PEJ is a feasible and safe method with a low procedure-related morbidity rate for patients where endoscopic placement via transillumination is not successful. Thus, the procedure is an attractive alternative to surgical tube placement. Long-term complications, mainly tube disturbances, can be treated easily.

The Offer of Advanced Imaging Techniques Leads to Higher Acceptance Rates for Screening Colonoscopy - a Prospective Study.

BACKGROUND: Colonoscopy plays a fundamental role in early diagnosis and management of colorectal cancer and requires public and professional acceptance to ensure the ongoing success of screening programs. The aim of the study was to prospectively assess whether patient acceptance rates to undergo screening colonoscopy could be improved by the offer of advanced imaging techniques. MATERIALS AND METHODS: Overall, 372 randomly selected patients were prospectively included. A standardized questionnaire was developed that inquired of the patients their knowledge regarding advanced imaging techniques. Second, several media campaigns and information events were organized reporting about advanced imaging techniques, followed by repeated evaluation. After one year the evaluation ended. RESULTS: At baseline, 64% of the patients declared that they had no knowledge about new endoscopic methods. After twelve months the overall grade of information increased significantly from 14% at baseline to 34%. The percentage of patients who decided to undergo colonoscopy because of the offer of new imaging methods also increased significantly from 12% at baseline to 42% after 12 months. CONCLUSIONS: Patients were highly interested in the offer of advanced imaging techniques. Knowledge about these techniques could relatively easy be provided using local media campaigns. The offer of advanced imaging techniques leads to higher acceptance rates for screening colonoscopies.

Digital Chromoendoscopy With i-Scan for In Vivo Prediction of Advanced Colorectal Neoplasia: A Multicenter Study.

BACKGROUND: Recent studies have analyzed the potential of advanced endoscopic imaging techniques for differentiating hyperplastic and adenomatous colorectal lesions. Latest endoscopic resection techniques now also allow for treatment of more advanced staged lesions including treatment of early cancerous lesions. AIMS: To assess the potential of the i-scan technology to differentiate between adenomatous polyps and advanced staged neoplasia. METHODS: Consecutive patients undergoing colonoscopy at a tertiary referral center were included. After a dedicated training, participating endoscopists underwent a review of 298 unknown images of colonic lesions to assess colorectal lesion histology. RESULTS: Overall accuracy for prediction of advanced staged neoplasia was 92.2% (sensitivity: 94.2%, specificity 90.9%). The positive and negative predictive values were calculated as 87.5% and 95.9%, respectively. The κ-value for differentiating adenomatous polyps and advanced staged neoplasia was 0.8193 (0.7894 to 0.8492). Intraobserver agreement was calculated with a κ-value of 0.9301 (0.8875 to 0.9727). CONCLUSIONS: Accurate interpretation of i-scan images for prediction of advanced colorectal neoplasia can successfully be performed even by nonexpert endoscopists with a high overall accuracy and excellent interobserver agreements.

Jejunitis and brown bowel syndrome with multifocal carcinogenesis of the small bowel.

This is the first report describing a case where prolonged, severe malabsorption from brown bowel syndrome progressed to multifocally spread small bowel adenocarcinoma. This case involves a female patient who was initially diagnosed with chronic jejunitis associated with primary diffuse lymphangiectasia at the age of 26 years. The course of the disease was clinically, endoscopically, and histologically followed for 21 years until her death at the age 47 due to multifocal, metastasizing adenocarcinoma of the small bowel. Multiple lipofuscin deposits (so-called brown bowel syndrome) and severe jejunitis were observed microscopically, and sections of the small bowel showed dense lymphoplasmacytic infiltration of the lamina propria as well as blocked lymphatic vessels. After several decades, multifocal nests of adenocarcinoma cells and extensive, flat, neoplastic mucosal proliferations were found only in the small bowel, along with a loss of the mismatch repair protein MLH1 as a long-term consequence of chronic jejunitis with malabsorption. No evidence was found for hereditary nonpolyposis colon carcinoma syndrome. This article demonstrates for the first time multifocal carcinogenesis in the small bowel in a malabsorption syndrome in an enteritis-dysplasia-carcinoma sequence.

Brown bowel syndrome: a rare complication in diseases associated with long-standing malabsorption.

BACKGROUND/AIMS: Longtime chronic malabsorption may among other things cause a lack of liposoluble vitamins. Vitamin E deficiency can lead to formation of lipofuscin aggregates. Its deficiency is also associated with an increased lipofuscinosis of the bowel, i.e. brown bowel syndrome. METHODS: Systematic research via Medline on brown bowel syndrome, lipofuscinosis, and vitamin E deficiency was performed. We combined our own clinical experience and a review of the literature for this paper. Its goal is to inform about the possible consequences of severe malabsorption and brown bowel syndrome. RESULTS: Systematic data about the occurrence of severe malabsorption and brown bowel syndrome are rare. Only about 27 scientific reports can be found on this subject. Brown bowel syndrome is found mostly in conjunction with vitamin E deficiency and lipofuscinosis of the bowel. The clinical findings are caused by both malabsorption and lipofuscinosis. Case reports show a therapeutic effect of vitamin E. CONCLUSION: Vitamin deficiency caused by longtime chronic malabsorption can lead to the development of brown bowel syndrome, which is seen as the expression of lipofuscinosis of the bowel, and can cause further clinical disorders. Patients with malabsorption should therefore be monitored regarding their vitamin E levels.

Colon capsule endoscopy: detection of colonic polyps compared with conventional colonoscopy and visualization of extracolonic pathologies.

BACKGROUND: Conventional colonoscopy (CC) is the gold standard for diagnostic examination of the colon. However, the overall acceptance of this procedure is low due to patient fears of complications or embarrassment. Colon capsule endoscopy (CCE) represents a minimally invasive, patient-friendly procedure that offers complete visualization of the entire intestine. OBJECTIVE: To assess the PillCam Colon 2 (Given Imaging Ltd, Israel) capsule with regard to feasibility, sensitivity and specificity for the detection of colonic pathologies and additional recorded extracolonic findings. METHODS: CCE was performed before CC in patients indicated for CC for known or suspected colonic disease. The results of both techniques were compared with regard to polyp detection. Additionally, bowel preparation and extracolonic pathologies were analyzed. RESULTS: Twenty-four patients (mean age 51.1 years) were included in the analysis. Visualization of the colon was complete in 23 CCs and 17 CCEs. No adverse events or major technical failures occurred. CC detected 47 polyps and CCE detected 43 polyps of any size (per-finding sensitivity 90.9%, specificity 67.6%). The accuracy of CCE in detecting polyp carriers was 81.5% (per-patient analysis). On average, the colon was adequately cleansed in 90.1% of patients. CCE identified esophageal, gastric and small bowel pathologies in seven (24%), nine (38%) and 14 (58%) patients, respectively. CONCLUSIONS: CCE proved to be technically feasible and safe. Acceptable sensitivity and moderate specificity levels in polyp detection were recorded. Bowel preparation was adequate in most patients. Because extracolonic pathologies were effectively visualized, new indications for the PillCam Colon 2 may be defined.

Long term follow up of through-the-scope balloon dilation as compared to strictureplasty and bowel resection of intestinal strictures in crohn's disease.

BACKGROUND & AIMS: Ileo-colonic strictures are common complication of Crohn's disease (CD), and may result in repeated endoscopic or surgical therapy with a risk of further complications, such as perforation or short bowel syndrome. Strictures develop as a consequence of tissue remodelling and fibrosis due to chronic inflammation. This study compares the outcome of CD patients undergoing primarily endoscopic treatment with those undergoing surgery at an university hospital. METHODS: In this study we retrospectively included 88 CD patients with intestinal strictures (37 males, 51 females, mean age 40 years, range 19-65 years) of both our medical and our surgical department, who underwent either surgical or endoscopic therapy between January 2002 and January 2006 with prospective, controlled follow-up, extended till January 2010 (mean follow-up period: 5 years; range 4-8 years). The primary end-point was operation- and symptom-free time. Patients were primarily divided into four groups: only surgical therapy, only endoscopic therapy, endoscopy with subsequent surgery, and initial surgical therapy followed by endoscopic dilations. RESULTS: 53% of all patients remained surgery-free with mean follow-up of 49 months; a single endoscopic dilation was sufficient enough in 9 patients to achieve a surgery-free time of 51 months, other patients required up to 5 dilations. The average interval between first and second dilation was 6.5 months, between second and third 10.5 months. In the group of patients with only endoscopic therapy, surgery- and symptom-free time was shorter, as compared to the group of only surgical therapy. We found that stenoses in the surgical group with an average length of 6.5 cm were as expected longer, as compared to the endoscopic group (3 cm, ranging from 2-4 cm). The surgery-free time was 49 months (42-71 months, P = 0.723) with a symptom-free time of 12 months (4.5-46 months, P = 0.921). In the group of only surgically treated patients, 68.4% of the patients had only one stenosis, 18.4% had 2-3 stenoses and 13.2% more than 3 stenoses. In all patients the surgery- and symptoms- free time was 69 months (57-83 months, P = 0.850 and 0.908). The other two groups showed similar results. We found no significant effect of characteristic of stenosis (length, inflammation, the number of stenoses), injection of prednisolone, disease activity at the time of dilation and medication at the time of dilation on the long-term outcome. Importantly, the success of symptom free time correlated with the diameter of the balloon. CONCLUSIONS: Endoscopic dilation should be considered as a first-line therapy for short, accessible, fibrotic strictures. Careful patient selection and proper diagnostic imaging pre-procedure are essential requirements for safe and successful treatment. The balloon diameter seems to correlate positively with the long term outcome of dilation. However, at ever shorter intervals between endoscopic interventions, surgery should be discussed as an option for further treatment.

Granulomatous lung disease requiring mechanical ventilation induced by a single application of oxaliplatin-based chemotherapy for colorectal cancer: a case report.

Combined chemotherapeutic regimens in conjunction with oxaliplatin are considered safe and effective treatment options in the clinical management of metastatic colorectal cancer. A 62-year-old male patient with a metastatic rectal carcinoma developed a pulmonary reaction after the first application of the combined standard chemotherapy regimen (5-fluorouracil and sodium folinic acid as a 24 h infusion and oxaliplatin). Following the first dose of chemotherapy, the patient developed acute dyspnoea and fever. A computerised scan of the chest revealed bilateral pulmonary patchy consolidation. Despite high-dose empiric antibiotic and antimycotic treatment, no clinical improvement was seen. The patient's condition deteriorated, and he required invasive mechanical ventilation. Diagnostic thoracoscopic wedge resections were performed for further diagnosis. The histological workup revealed distinct granulomatous inflammation, but no microbial pathogens were to be found. Thereupon, a drug-induced reaction to chemotherapy was suspected and high-dose steroid treatment initiated. Subsequently, the patient's respiratory condition improved and he was extubated. The present case exemplifies the rare course of a bilateral pneumonia-like, drug-induced granulomatous reaction following a single application of oxaliplatin. In addition to the known side effects of oxaliplatin-containing combination chemotherapy, unexpected serious adverse events in the form of pulmonary toxicities should also be taken into account.

Normalized autofluorescence imaging diagnostics in upper GI tract: a new method to improve specificity in neoplasia detection.

BACKGROUND & AIMS: This study was performed to improve the autofluorescence imaging (AFI) in the upper GI tract by applying a new method of normalized autofluorescence (NAFI) obtained via tri-modal imaging. OBJECTIVE: NAFI may provide lower false positive rate to achieve ultimately better specificity at acceptable sensitivity. PATIENTS AND METHODS: This is a prospective, controlled single-centre study. 18 patients with suspected esophagus or stomach cancer undergoing esophagogastroduodenoscopy (EGD) were enrolled between February and May 2010. After endoscopy each patient was assigned into one of two groups: (1) non-cancer, including inflammation; (2) cancer group. EGDs were performed using video white light endoscopy, followed by AFI/NAFI. The targeted biopsy samples were taken from the abnormal areas as well as from adjacent mucosa. NAFI was compared versus AFI for cancer diagnostics in terms of specificity and sensitivity. RESULTS: NAFI detected all neoplastic lesions. WLE or NBI detected no additional neoplasia. The AFI displayed mucosal inflammation and carcinomas of esophagus and stomach as dark red color, the normal mucosa background was displayed as light green. The NAFI didn't differentiate inflamed tissue from normal in majority of cases, but in tumorous mucosa, the cancer areas were detected precisely. AFI shows 100% sensitivity but 50% specificity which correlates with previous literature data. On the other hand, NAFI demonstrated lower sensitivity (88%) but higher specificity compared to AFI (69%). CONCLUSIONS: Measuring the NAFI instead of the AFI was found improving the specificity of cancer diagnosis. Use of fiber-optic endoscopes to analyze AFI and possible endoscopic and histological sampling error are the main potential limitations of this method.

Long-Term Relapse-Free Survival by Interdisciplinary Collaboration in a Patient with Metastatic Pancreatic Cancer (UICC IV).

INTRODUCTION: The prognostic outlook for patients suffering from pancreatic cancer is generally poor. Particularly in cases of advanced and metastatic disease, long-term relapse-free survival may be achieved only in a few cases. CASE REPORT: A 45-year-old patient presented with metastatic pancreatic cancer. Liver metastases had been intra-operatively confirmed by histology. Prior to initiating treatment, a portacath was surgically implanted. Subsequently, the patient received a weekly dose of 1,000 mg/m(2) gemcitabine combined with 2,000 mg/m(2) high-dose 5-fluorouracil as a 24-hour infusion for palliative treatment. As the patient was suffering from a stenosis of the ductus hepaticus communis, an endoprosthesis was primarily implanted. After 18 applications of chemotherapy during which only low toxic side effects such as nausea, vomiting and alopecia (NCI-CTC grade 1) presented, a partial remission of the primary tumor was observed. In the course of chemotherapy treatment, the carbohydrate antigen 19-9 tumor marker value normalized. Thus, the interdisciplinary tumor board of the University of Erlangen decided to perform a laparoscopy to evaluate the status of liver metastases after palliative chemotherapy treatment. Subsequently, the primary tumor could be completely resected (pT2, pN0, pM0, L0, V0, G2, R0); liver metastases were not observed. Eight years after the initial diagnosis, the patient is relapse-free, professionally fully integrated and presents with an excellent performance status. CONCLUSION: Patients suffering from metastatic pancreatic cancer may benefit from treatment combinations with palliative intent. In singular cases, patients may even have a curative treatment option, provided a close interdisciplinary collaboration exists.

Palliative first-line therapy with weekly high-dose 5-fluorouracil and sodium folinic acid as a 24-hour infusion (AIO regimen) combined with weekly irinotecan in patients with metastatic adenocarcinoma of the stomach or esophagogastric junction followed by secondary metastatic resection after downsizing.

BACKGROUND: The aim of this retrospective study was to evaluate the efficacy and safety of weekly high-dose 5-fluorouracil (5-FU)/folinic acid (FA) as 24-h infusion (AIO regimen) plus irinotecan in patients with histologically proven metastatic gastroesophageal adenocarcinoma (UICC stage IV). MATERIAL/METHODS: From 08/1999 to 12/2008, 76 registered, previously untreated patients were evaluable. Treatment regimen: irinotecan (80 mg/m²) as 1-h infusion followed by 5-FU (2000 mg/m²) combined with FA (500 mg/m²) as 24-h infusion (d1, 8, 15, 22, 29, 36, qd 57). RESULTS: Median age: 59 years; male/female: 74%/26%; ECOG ≤1: 83%; response: CR: 1%, PR: 16%, SD: 61%, PD: 17%, not evaluable in terms of response: 5%; tumor control: 78%; median OS: 11.2 months; median time-to-progression: 5.3 months; 1-year survival rate: 49%; 2-year survival rate: 17%; no evidence of disease: 6.6%; higher grade toxicities (grade 3/4): anemia: 7%, leucopenia: 1%, ascites: 3%, nausea: 3%, infections: 12%, vomiting: 9%, GI bleeding of the primary tumor: 4%, diarrhea: 17%, thromboembolic events: 4%; secondary metastatic resection after downsizing: 16 patients (21%), R-classification of secondary resections: R0/R1/R2: 81%/6%/13%, median survival of the 16 patients with secondary resection: 23.7 months. CONCLUSIONS: Combined 5-FU/FA as 24-h infusion plus irinotecan may be considered as an active palliative first-line treatment accompanied by tolerable toxicity; thus offering an alternative to cisplatin-based treatment regimens. Thanks to efficient interdisciplinary teamwork, secondary metastatic resections could be performed in 16 patients. In total, the patients who had undergone secondary resection had a median survival of 23.7 months, whereas the median survival of patients without secondary resection was 10.1 months (p≤0.001).