Update on the management of elderly patients with colorectal cancer

Colorectal cancer (CRC) is one of the most common tumours worldwide, and 70% of CRC patients are over 65 years of age. However, the scientific evidence available for these patients is poor, as they are underrepresented in clinical trials. Therefore, a group of experts from the Oncogeriatrics Section of the Spanish Society of Medical Oncology (SEOM), the Spanish Cooperative Group for the Treatment of Digestive Tumours, (TTD) and the Multidisciplinary Spanish Group of Digestive Cancer (GEMCAD) have reviewed the scientific evidence available in older patients with CRC. This group of experts recommends a multidisciplinary approach and geriatric assessment (GA) before making a therapeutic decision because GA predicts the risk of toxicity and survival and helps to individualize treatment. In addition, elderly patients with localized CRC should undergo standard cancer resection, preferably laparoscopically. The indication for adjuvant chemotherapy (CT) should be considered based on the potential benefit, the risk of recurrence, the life expectancy and patient comorbidities. When the disease is metastatic, the possibility of radical treatment with surgery, radiofrequency (RF) or stereotactic body radiation therapy (SBRT) should be considered. The efficacy of palliative CT is similar to that seen in younger patients, but elderly patients are at increased risk of toxicity. Clinical trials should be conducted with the elderly population and include GAs and specific treatment plans (AU)

Update on the management of elderly patients with colorectal cancer.

Colorectal cancer (CRC) is one of the most common tumours worldwide, and 70% of CRC patients are over 65 years of age. However, the scientific evidence available for these patients is poor, as they are underrepresented in clinical trials. Therefore, a group of experts from the Oncogeriatrics Section of the Spanish Society of Medical Oncology (SEOM), the Spanish Cooperative Group for the Treatment of Digestive Tumours, (TTD) and the Multidisciplinary Spanish Group of Digestive Cancer (GEMCAD) have reviewed the scientific evidence available in older patients with CRC. This group of experts recommends a multidisciplinary approach and geriatric assessment (GA) before making a therapeutic decision because GA predicts the risk of toxicity and survival and helps to individualize treatment. In addition, elderly patients with localized CRC should undergo standard cancer resection, preferably laparoscopically. The indication for adjuvant chemotherapy (CT) should be considered based on the potential benefit, the risk of recurrence, the life expectancy and patient comorbidities. When the disease is metastatic, the possibility of radical treatment with surgery, radiofrequency (RF) or stereotactic body radiation therapy (SBRT) should be considered. The efficacy of palliative CT is similar to that seen in younger patients, but elderly patients are at increased risk of toxicity. Clinical trials should be conducted with the elderly population and include GAs and specific treatment plans.

Reliability of Ki-67 Determination in FNA Samples for Grading Pancreatic Neuroendocrine Tumors.

Neuroendocrine pancreatic tumors (PanNETs) are graded on the basis of their proliferative activity. Cytological samples are commonly the only samples available, but the determination of Ki-67 in cytology and its reliability as a measure of tumor mitotic activity is not well settled. We have retrospectively reviewed all the cases of FNA under EUS control of PanNETs in a 10-year period (2006-2016) in the Hospital Clínico San Carlos (Madrid). We identified 10 PanNET cases with histological correlation. Median age was 49.4 years and the patients were mainly women. PanNETs were located more frequently in the tail of the pancreas, with a median size of 33.8 mm. None of our cases was a grade 3 tumor. The seven grade 1 tumors confirmed in histology had consistent Ki-67 in cytology. In three cases (30 %), there were discrepancies between the Ki-67 index measured in cytology and histology, and the differences ranged from 2 to 15 %; all these cases were grade 2 tumors in histology and were graded as grade 1 tumors in FNA material. Our results are consistent with previous studies which showed understaging when tumor grade was assessed in cytological samples, mainly in G2 tumors. Previous literature has shown that Ki-67 assessment in EUS-FNA samples is a useful tool to rule out G3 tumors, but can be problematic for distinguishing G1 and G2 tumors.

Tumores neuroendocrinos gastroenteropancreáticos: características clínicas, proceso diagnóstico y pronóstico en el Hospital Universitario Clínico San Carlos (Madrid) / Gastroenteropancreatic neuroendocrine tumors: Clinical characteristics, diagnosis and prognosis at Hospital Universitario Clínico San Carlos (Madrid)

INTRODUCCIÓN: Los tumores neuroendocrinos (TNE) representan un grupo de neoplasias originadas por células de la cresta neural y del endodermo con gran heterogenicidad en cuanto a localización, comportamiento clínico, agresividad y pronóstico. El páncreas y el tubo digestivo constituyen las localizaciones más frecuentes. MATERIAL Y MÉTODOS: Se ha realizado una revisión de casos diagnosticados de neoplasia neuroendocrina gastroenteropancreática (TNEGEP), tanto primaria como metastásica, en el Hospital Universitario Clínico San Carlos (HUCSC) entre enero de 2007 y mayo de 2012. Se han comparado los datos obtenidos con los aportados por el Registro del Grupo Español de Tumores Neuroendocrinos (RGETNE). RESULTADOS: El estudio constó de 78 pacientes. El tipo de tumor más común fue el gastroentérico no funcionante. Un 50,6% de los pacientes presentó metástasis al diagnóstico, siendo lo más prevalente la afectación ganglionar. Los TNEGEP localizados en el recto se acompañaron de un mayor porcentaje de metástasis. La supervivencia global a los 24 meses fue del 74,8%, estando en relación con el sexo, la expresión del Ki-67 y la presencia de enfermedad a distancia

INTRODUCTION: Neuroendocrine tumors are a group of neoplasms arising from the neural crest and endoderm and very heterogeneous as regards localization, clinical behavior, aggressiveness, and prognosis. Pancreas and gastrointestinal tract are the most common sites where neuroendocrine tumors can be found. MATERIAL AND METHODS: A review was made of all cases of neuroendocrine tumors diagnosed at Hospital Universitario Clínico San Carlos (HUCSC) from January 2007 to May 2012. Data were compared to the results provided by the Registry of the Spanish Group on Neuroendocrine Tumors (RGETNE). RESULTS: The study cohort comprised 78 patients. Gastroenteric nonfunctional tumors were the most common neoplasms. Metastases were found at diagnosis in 50.6% of patients, with nodal involvement being most prevalent. Tumors located in the rectum were associated to the highestrate of metastasis. Overall 2-year survival rate was 74.8% and was related to sex, Ki-67 expression, and presence of metastasis

[Gastroenteropancreatic neuroendocrine tumors: clinical characteristics, diagnosis and prognosis at Hospital Universitario Clínico San Carlos (Madrid)]. / Tumores neuroendocrinos gastroenteropancreáticos: características clínicas, proceso diagnóstico y pronóstico en el Hospital Universitario Clínico San Carlos (Madrid).

INTRODUCTION: Neuroendocrine tumors are a group of neoplasms arising from the neural crest and endoderm and very heterogeneous as regards localization, clinical behavior, aggressiveness, and prognosis. Pancreas and gastrointestinal tract are the most common sites where neuroendocrine tumors can be found. MATERIAL AND METHODS: A review was made of all cases of neuroendocrine tumors diagnosed at Hospital Universitario Clínico San Carlos (HUCSC) from January 2007 to May 2012. Data were compared to the results provided by the Registry of the Spanish Group on Neuroendocrine Tumors (RGETNE). RESULTS: The study cohort comprised 78 patients. Gastroenteric nonfunctional tumors were the most common neoplasms. Metastases were found at diagnosis in50.6% of patients, with nodal involvement being most prevalent. Tumors located in the rectum were associated to the highestrate of metastasis. Overall 2-year survival rate was 74.8% and was related to sex, Ki-67 expression, and presence of metastasis.

Impact of cetuximab in current treatment of metastatic colorectal cancer.

INTRODUCTION: Cetuximab is a chimeric monoclonal antibody targeting the EGFR, which has proven effective in patients with metastatic colorectal cancer (mCRC), wild-type Kirsten rat sarcoma viral oncogene homolog (KRAS). AREAS COVERED: The aim of this manuscript is to discuss the current impact of cetuximab in the most important scenarios of mCRC. We review the currently available data regarding the role of other biomarkers, such as the mutational status of neuroblastoma RAS viral (v-ras) oncogene homolog in identifying patients who could benefit most from anti-EGFR. In addition, a review is included of the most relevant clinical trials that have assessed the effectiveness of cetuximab in the management of patients with potentially resectable metastatic disease and in the first-line treatment of wild-type KRAS mCRC, as well as the impact of this anti-EGFR agent on patient quality of life. EXPERT OPINION: Cetuximab has had a progressive clinical development from the earliest to the later stages of the evolution of mCRC and has been consolidated as a therapeutic option for all scenarios of unresectable disease. Patient selection by analysis of KRAS mutations has been a fundamental event to increase efficiency, being a dynamic process that continues in assessment. There are few comparative data with other biological agents in combination with chemotherapy, although data from a recent study are promising.

Insulinoma maligno avanzado. Respuesta y toxicidad con everolimus / Advanced malignant insulinoma. Everolimus response and toxicity

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Prognostic factors and long-term outcome of pancreatic neuroendocrine neoplasms: Ki-67 index shows a greater impact on survival than disease stage. The large experience of the Spanish National Tumor Registry (RGETNE).

INTRODUCTION: Pancreatic neuroendocrine neoplasms (PNENs) are uncommon neoplasms with a wide spectrum of clinical behavior. The objective of this study was to assess in a large cohort of patients the relative impact of prognostic factors on survival. METHODS: From June 2001 through October 2010, 1,271 patients were prospectively registered online (www.getne.org) at the Spanish National Cancer Registry for Gastroenteropancreatic Neuroendocrine Tumors (RGETNE) by participating centers. Clinical and histopathological features were assessed as potential prognostic factors by uni- and multivariate analyses. RESULTS: Of 483 PNENs, 171 (35%) were functional (F) and 312 (65%) non-functional (NF). NF-PNENs were associated with a higher incidence of histological features denoting more aggressive disease, such as poor tumor differentiation, Ki-67 >20%, or vascular invasion (NF- vs. F-PNENs, respectively, p < 0.05). Nevertheless, functionality was not a significant predictor of survival (p = 0.19). Stage at diagnosis, Ki-67 index, tumor differentiation and surgical resection of the primary tumor were all significant prognostic factors in univariate analysis. However, Ki-67 (>20 vs. ≤2%) (hazard ratio (HR) 2.21, p = 0.01) and surgical resection (yes vs. no) (HR 0.92, p = 0.001) were the only independent predictors of survival in multivariate analysis. Among patients who underwent surgery, high Ki-67 index (HR 10.37, p = 0.02) and poor differentiation (HR 8.16, p = 0.03) were the only independent predictors of clinical outcome. CONCLUSION: Ki-67 index and tumor differentiation are key prognostic factors influencing survival of patients with PNENs and, in contrast to what it is observed for other solid malignancies, they seem to have a greater impact on survival than the extent of disease. This should be borne in mind by physicians in order to appropriately tailor therapeutic strategies and surveillance of these patients.

SEOM clinical guidelines for the adjuvant treatment of colorectal cancer.

Colorectal cancer is the third most common malignant neoplasm and the second cause of death by cancer in western countries. In this manuscript, the clinical guidelines of the Spanish Society of Medical Oncology (SEOM) for diagnosis and adjuvant treatment of colon cancer and rectal cancer are reported.

A phase II trial of gemcitabine and weekly high-dose 5-fluorouracil in a 48-hour continuous-infusion schedule in patients with advanced pancreatic carcinoma. A study of the Spanish Cooperative Group for Gastrointestinal Tumour Therapy (TTD)

Aim. A multi-centred, open-labelled, phase II study containing 46 patients was conducted to evaluate the clinical benefit of gemcitabine (1,400 mg/m2) combined with 5-FU (3 g/m2) in a 48h continuous infusion (CI). Methods. Both drugs were administered on days 1, 8 and 15 of every 4 week cycle in chemotherapy-naïve patients with locally advanced un-resectable metastatic pancreatic carcinoma. The minimum follow-up was 6 months. Results. Clinical benefit response was the primary endpoint and this was achieved by 24.4% of the patients. Quality of life (QoL) improved in 16.6% of patients. Objective response was observed in 7% of the patients. The median progression-free survival (PFS) was 14.4 weeks and the median overall survival (OS) time was 22.7 weeks. One-year survival was 25%. The most frequent grade 3-4 toxicities were neutropenia (45%), mucositis (7.5%) and hyperbilirubinaemia (10.5%). Conclusions. This schedule was not superior in terms of clinical benefit, response rate, PFS and OS than standard gemcitabine treatment

Epididymal metastases as the first sign of a colon cancer recurrence.

Metastastic tumours involving the epididymis are rare and most often found in patients with disseminated disease. It is even more unusual when the metastasis of the epididymis is the first sign of tumour recurrence. We report a case of an asymptomatic recurrent colon carcinoma presenting as metastasis in the epididymis. Although metastatic cancer presenting as an intra-scrotal mass is extremely rare, it should be considered as a possibility in patients who present with a mass involving the testicle or epididymis.

Epididymal metastases as the first sign of a colon cancer recurrence

Metastastic tumours involving the epididymis are rare and most often found in patients with disseminated disease. It is even more unusual when the metastasis of the epididymis is the first sign of tumour recurrence. We report a case of an asymptomatic recurrent colon carcinoma presenting as metastasis in the epididymis. Although metastatic cancer presenting as an intra-scrotal mass is extremely rare, it should be considered as a possibility in patients who present with a mass involving the testicle or epididymis