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Die Überwachung der Adhärenz für orale antineoplastische Therapien hämatologischer und onkologischer Erkrankungen stellt ein großes Problem insbesondere bei älteren und immobilen Patienten im ländlichen Raum dar. Das Projekt „Mobiler Onkologischer Dienst“ (MOD) wurde zur Verbesserung der Versorgungssituation in der Region Landshut eingeführt. Die vorliegende Untersuchung dient der Evaluation dieses innovativen Versorgungsmodells bezüglich Patientenadhärenz, ökonomischer Aspekte und Patientenzufriedenheit. Für jeden Besuch wurden allgemeine Kennzahlen, Medikation, Nebenwirkungen und Krankenhausaufenthalte durch die jeweilige MOD-Assistentin registriert. Die Patientenzufriedenheit wurde durch Fragebögen ermittelt. Durchschnittlich 32 Patienten wurden im Mittel 4‑ bis 5‑mal pro Quartal besucht. Der durchschnittliche zeitliche Aufwand pro Besuch und Patient betrug 63 min, der durchschnittliche Anfahrtsweg 20 km. Die Umfrage belegte eine sehr hohe Patientenzufriedenheit. Krankenhausaufenthalte durch therapieassoziierte Toxizitäten konnten weitestgehend vermieden werden. Die durch den MOD verabreichten und überwachten Therapien verursachten Kosten von teilweise mehreren Tausend Euro pro Monat. Der MOD erreichte eine Reduktion der Fahrtkosten von 10–15 % gegenüber Taxen oder Fahrdiensten und um bis zu 60 % gegenüber Krankentransporten. Der zeitliche Aufwand für die Patienten oder deren Angehörige konnte auf ein Viertel reduziert werden. Der MOD stellt ein effektives und kostensparendes Instrument zur Überwachung der Patientenadhärenz, Vermeidung von schwerwiegenden Nebenwirkungen und Krankenhausaufenthalten dar und führt zu einer hohen Patientenzufriedenheit. Surveillance of adherence to oral anti-proliferative therapy for hematological and oncological diseases is a crucial issue, especially in elderly and immobile patients in rural areas. The project „Mobile oncological service“ (MOD) was introduced to improve the patient-centered care situation in the region of Landshut, Bavaria, Germany. The aim of the current study was to evaluate an innovative model of patient care in terms of patient adherence, economical aspects and patient satisfaction. For each visit general data, medication, side effects and hospitalizations were recorded by the MOD assistant. Patient satisfaction was evaluated using a questionnaire. On average 32 patients were visited 4–5 times per quarter year. Each visit took an average of 63 min and the mean travelling distance was 20 km. The survey showed a very high level of patient satisfaction. Hospitalization caused by therapy-associated side effects could be avoided to the greatest possible extent. The therapies administered and monitored by the MOD caused costs of sometimes several thousand euros per month. The MOD achieved a reduction of travelling costs of 10–15 %, compared to taxis or transportation services and up to 60 % compared to transportation by an ambulance. The amount of time needed by patients and their relatives could be reduced to 25 %. The MOD represents an efficient and cost-saving instrument for monitoring patient adherence, avoidance of severe side effects and hospitalizations and leads to a high patient satisfaction.

Das Onkologische und Palliativmedizinische Netzwerk Landshut ist ein Lösungsansatz für strukturschwache ländliche Regionen, um eine adäquate Versorgung schwerstkranker Patienten zu verbessern, vor allem durch eine enge Verquickung der ambulanten und stationären Leistungserbringer. Diese Netzwerke optimieren nicht nur die Patientenversorgung, sondern können auch kosteneffektiv arbeiten. The Oncologic and Palliative Network Landshut is a problem-solving approach to structurally weak rural areas to improve an adequate care of critically ill patients, especially by a close involvement of outpatient and inpatient care providers. These networks not only improve the medical and nursing care of patients, but can also be cost-effective.

Abstract:  The long-term results of both pretreated and previously untreated patients with hairy cell leukemia (HCL) using uniformly a single 7-day course of 2-chlorodeoxyadenosine (2-CdA) by continuous infusion are reported. In addition, the probability of obtaining another response with this drug in patients who relapsed after 2-CdA treatment will be addressed. Forty-two consecutive patients (32 men, 10 women) with a median age of 56 years (range 32–75) at the time of initiation of 2-CdA treatment were analyzed. Ten patients were pretreated with either splenectomy (n=6) or interferon a (n=8) or deoxycoformycin (dCF) (n=3) or with all procedures in sequence. Two patients who did not respond to dCF did respond to 2-CdA. Median time to start of 2-CdA treatment of the ten pretreated patients was 47 months (10–160); 41 of the 42 (98%) achieved CR, and one patient reached a good partial response with a single cycle of 2-CdA. Ten of the 42 patients had no toxicities at all. Toxicities (WHO grades I–IV) were mainly of grades I and II; in one patient with a preexisting brain injury grade III neurotoxicity was seen, and one patient suffered a grade-IV infectious complication. Bone marrow biopsies were performed at the time of recovery of hematopoiesis, thereafter at 2- to 3-month intervals, then at 6 months, and finally annually in all 42 patients. Median follow-up is 32 months (2–72). Disease-free survival from start of 2-CdA treatment is 75% at 6 years; 6/42 patients relapsed. Three of these patients were treated with 2-CdA again. All three patients reached another CR (+1, +2, +13). Four of the 42 patients had a second malignancy (carcinomas of the bladder, breast, cervix, prostate gland) before receiving 2-CdA. One patient died in CR due to the second malignancy. 2-CdA is a safe and effective treatment of HCL, inducing complete remissions in the majority of patients with only a single cycle of 2-CdA and a paucity of toxities. Responses are durable and long lasting. Patients relapsing following a treatment with 2-CdA seem to respond to this drug again.

Summary A patient in an intensive care unit experienced severe esophageal bleeding caused by erosion of a lusorian artery. The lusorian artery is a rare variant of the right subclavian artery. It originates in the descending aortic arch and crosses behind the esophagus to the right, sometimes generating esophageal compression. The patient's condition required respirator therapy and placement of a duodenal tube. At the point of crossing over of the lusorian artery and the esophagus, the duodenal tube caused esophageal necrosis, leading to erosion of the lusorian artery. This resulted in extensive esophageal bleeding, which at last required surgical intervention. To attain proper treatment and to avoid unnecessary diagnostic and therapeutic approaches, a lusorian artery lesion has to be included in the differential diagnosis of upper gastrointestinal bleeding.

The prognosis of elderly patients with mantle cell lymphoma (MCL) is poor. Despite R-CHOP, only low rates of complete remissions (CR) are obtained and almost all patients relapse. Median overall survival (OS) used to be far below 5 years. Within the European MCL Network we performed a randomized intergroup trial to investigate both whether a fludarabine-containing induction regimen could improve the CR-rate, and whether maintenance with rituximab could prolong remission duration.Patients with stage II-IV MCL >60 yrs not eligible for high-dose therapy were randomized between either 8 × R-CHOP-21 (day 1: rituximab 375 mg/m2, cyclophosphamide 750 mg/m2, doxorubicin 50 mg/m2, vincristine 1.4 mg/m2, max 2 mg and day 1–5 prednisone 100 mg) or 6 × R-FC-28 (rituximab 375 mg/m2 day 1, fludarabine 30 mg/m2 + cyclophosphamide 250 mg/m2, both iv day 1–3). Responding (CR, CRu, PR) patients underwent a second randomization between maintenance with rituximab one dose every 2 months or interferon-alfa (IFN; regular IFN weekly 3×3 MIU or pegylated IFN 1×1 μg/kg), both given until progression. First randomisation for induction therapy - R-CHOP vs R-FC: Between Jan 2004 and Oct 2010, 560 patients were entered; 457 were evaluable for response to induction. Median age was 70 yrs, 70% male, 83% stage IV, 41% intermediate and 50% high-risk MIPI. Whereas CR rates after R-FC and R-CHOP were similar (38 vs 34% CR, 52 vs 50% CR/CRu, respectively), the overall response rate was lower after R-FC (78% vs 87%; p=0.0508). Progressive disease was more frequent during R-FC (15% vs 5%). Of note, median OS was significantly inferior after R-FC (40 vs 64 months; p=0.0072). More patients died after initial progression (14% vs 4%) or in first remission (11% vs 3%) in the R-FC arm compared to R-CHOP. Hematologic grade 3–4 toxicities were more frequent during R-FC, especially thrombocytopenia (40% vs 17%). Non-hematologic grade 3–4 toxicity was rare (below 7% each), except neutropenic fever (12% R-FC; 18% R-CHOP) and infections (16% R-FC; 14% R-CHOP). Second randomisation for maintenance therapy - Interferon-alpha vs Rituximab: From the responding patients, 310 underwent the second randomization. Sixty-one percent of patients had a CR/CRu upon induction therapy. Fifty-eight percent had received R-CHOP induction. Rituximab maintenance almost doubled the remission duration compared with IFN (at 4-yrs 57% vs 26% in remission; HR 0.54, 0.35–0.87; p=0.0109). Overall survival did not differ between both maintenance arms (p=0.17). However, the subcohort of R-CHOP-treated patients showed a significant advantage after rituximab maintenance (4-yr OS 87% vs 57% after IFN; p=0.0061). Hematologic grade 3–4 toxicity was higher in the IFN arm (leukocytopenia 33% vs 16%; thrombocytopenia 15% vs 6%); non-hematologic grade 3–4 toxicity was rare, except for infections (8% IFN; 7% rituximab). R-FC followed by rituximab resulted in the highest infection rate (CTC grades 1–4: 50%), whereas all other combinations (R-CHOP followed by rituximab or IFN, and R-FC followed by IFN) ranged between 25–35%. Patients in CR/CRu or PR after induction who did not receive any maintenance for various reasons, mainly based upon patient's decisions or ongoing cytopenia after induction (n = 104), had a poor outcome (median remission duration 18 months).Induction therapy with R-FC is discouraged for elderly patients with MCL, whereas R-CHOP induction followed by rituximab maintenance should be considered the new standard for elderly MCL patients, to which new regimens need to be compared.Off Label Use: rituximab maintenance for mantle cell lymphoma. Geisler:Roche: Consultancy, Research Funding; Celgene: Consultancy; GSK: Consultancy. Tilly:Roche: Honoraria, Membership on an entity's Board of Directors or advisory committees. Hiddemann:Roche Pharma: Honoraria, Research Funding. Dreyling:Roche: Research Funding, Scientific advisory board, Speakers Bureau.

Abstract 439This icon denotes a clinically relevant abstract