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Die kontrastverstärkte Mehrschicht-Computertomographie (MSCT) hat sich als das Standard-Schnittbildverfahren sowohl zur Diagnostik als auch zur Therapiekontrolle von Leberläsionen durchgesetzt. Zur Abklärung der lokalen Verhältnisse vor einer Leberteilresektion kann die diffusionsgewichtete Magnetresonanztomographie (DWI-MRT) wichtige zusätzliche Befunde liefern. Um das Kriterium der R0-Resektion zu erfüllen, erscheint ein Sicherheitsabstand von 0,5 mm ausreichend. Eine neoadjuvante Chemotherapie mit dem Ziel, die Tumorgröße zu verringern, kann parallel zur Pfortaderembolisation durchgeführt werden, ohne dass die perioperative Morbidität und Mortalität beeinträchtigt wird. Bezüglich des Managements primär resektabler Lebermetastasen besteht dringender Studienbedarf. Trotz der eher geringen Evidenz wird die adjuvante Chemotherapie in Deutschland derzeit breiter befürwortet als die perioperative Chemotherapie. Auch bezüglich der präoperativen Therapie bei Patienten mit (noch) nicht resektablen Lebermetastasen besteht erheblicher Studienbedarf. Bei KRAS-Wildtyp-Tumoren werden mit einer Cetuximab/Chemotherapie-Kombination hohe Ansprechraten (im Sinne einer metrischen Verkleinerung der Metastasen) erzielt. Bevacizumab/Chemotherapie-Kombinationen führen zu hohen pathohistologischen Komplett- und Partialremissionen. Welches der beste Parameter zur Erfolgsbeurteilung einer präoperativen Therapie ist, ist derzeit noch unbekannt, weshalb Vergleichsstudien mit dem Überleben als hartem Endpunkt durchgeführt werden müssen.

Even though adjuvant systemic therapy significantly increases 5-year survival rates for resectable gastric or gastroesophageal carcinoma, quality assurance research has shown that in practice it is often not given. The European standard, perioperative chemotherapy, is based on results of the MAGIC trial (3 cycles of ECF - epirubicin, cisplatin, 5-FU as infusion before and after surgery). It is to be expected that oral capecitabine will replace infusional 5-FU in perioperative treatment, as in the palliative setting. This change has already taken place in many institutions. For metastatic and locally advanced esophageal and gastric carcinoma, the results of clinical trials over recent years have led to the following concrete changes: the importance of platinum has been confirmed. Oxaliplatin can replace cisplatin. Capecitabine can replace 5-FU. If docetaxel is given in addition to platinum/5-FU, this doubles 2-year survival (with significant toxicity). Targeted drugs such as cetuximab, panitumumab, and bevacizumab are currently undergoing clinical trials.

A standardized procedure for dealing with nonresectable liver metastases does not currently exist. It is important that an interdisciplinary approach to treatment be taken, in order to look for the optimum solution for each individual patient. High response rates appear to be important, in order to make more patients with nonresectable liver metastases 'resectable' and thus provide a chance of cure. A series of randomized phase II-III trials found a clear increase in response rates and an improvement in the R0 resection rate as a result of more intensive therapy (triple chemotherapy or combination chemotherapy plus cetuximab or bevacizumab). In the NO16966 trial, too, under blinded conditions, more liver metastasis resections were carried out among patients who had received bevacizumab than among patients in the control arm without bevacizumab, although the response rates in the two arms were the same. A gap of 6-8 weeks between the last dose of bevacizumab and surgery is clinically optimal from the point of view of perioperative safety. If neoadjuvant treatment is given, then resection should be carried out as soon as the metastases are resectable. If the patient's response is not adequate, then consideration should be given to an adaptation or change of the treatment regimen. Regular evaluation for secondary resectability is important. Surgically, in addition to 2- or multi-stage surgery, other possible techniques include portal embolization and intraoperative ablation. The goal remains R0 resection. In order to minimize complications, clinicians must select patients carefully, take account of comorbidities, and know the critical resection volume.

Das Kolonkarzinom gehort zu den haufigsten Tumorentitaten und wird bei der Mehrheit der Patienten im lokalisierten Stadium diagnostiziert. Das Rezidivrisiko schwankt je nach Stadium zwischen 10 und 80%, kann aber bei Risikopatienten mit einer postoperativen Chemotherapie in relevantem Mase gesenkt werden. Im Stadium III ist die adjuvante Chemotherapie eindeutig indiziert, sofern keine Kontraindikationen vorliegen. Im Stadium II hat die Chemotherapie einen nur marginalen Effekt auf das rezidivfreie Uberleben und wird daher nicht routinemasig empfohlen. Bei Vorliegen von Risikofaktoren wie Perforation, unzureichender Anzahl untersuchter Lymphknoten etc. kann die Chemotherapie jedoch auch im Stadium II eine relevante Verbesserung bringen und sollte individuell mit den Patienten diskutiert werden. Es wird die Kombination aus Oxaliplatin plus 5-FU/Folinsaure (FOLFOX) empfohlen. Alternativ konnen auch orale Fluoropyrimidine als Monotherapie gegeben werden.

Das multimodale Management sowie innovative chirurgische Techniken haben die Therapie und Prognose von Patienten mit Lebermetastasen vollig verandert und deutlich verbessert. Ob Patienten mit resektablen Lebermetastasen eine neoadjuvante und/oder adjuvante Chemotherapie erhalten sollten, wird derzeit noch kontrovers diskutiert. Ist eine R0-Resektion moglich (primar oder nach Vorbehandlung), sollte diese aus chirurgischer Sicht ohne Verzogerung erfolgen. Eine limitierte Resektion (Subsegment/Segment/nichtanatomische Resektion) ist adaquat, wenn die Metastasen komplett entfernt werden konnen, und hat den Vorteil des Erhalts von mehr funktionalem Lebergewebe, um im Fall eines Rezidivs eine Zweit-und eventuell Drittresektion vornehmen zu konnen. Ein geringer Sicherheitsabstand (

Background: The optimum regimen for advanced gastric cancer requires definition. This multicentre phase II study evaluated docetaxel-cisplatin combination in advanced gastric cancer. Methods: Chemotherapy-naïve patients with locally advanced or metastatic disease received docetaxel plus cisplatin (75/75 mg/m2) every 21 days for up to 9 cycles. Endpoints included tumour response, time to progression, overall survival and toxicity. Results: Of 113 patients recruited, 88 were completely evaluable. The median age was 58 years, and most patients had metastatic disease. The overall response rate was 29.6%. Five patients (5.7%) achieved a complete response and 21 patients (23.9%) had a partial response. Tumour control, including stable disease, was achieved in 57 patients (64.8%). The median time to progression and median overall survival time was 4.8 and 8.7 months, respectively. The major toxicity was haematological: 37.5% of patients experienced grade 3–4 neutropenia, whereas febrile neutropenia was observed in only 2% of patients. Conclusion: Docetaxel-cisplatin was active with a predictable and manageable toxicity profile.

Background: An isolated perfusion may lead to a higher concentration of cytostatics within the target tissue, which can be associated with a high response rate and longer survival in addition to a low rate of side effects in comparison with systemic palliative chemotherapy. The aim of the present study was to investigate the pharmacokinetics of mitomycin C utilizing the aortic stop flow technique with commercially available tools in patients with advanced pancreatic carcinoma. Methods: Seventeen patients with unresectable or metastasized pancreatic carcinoma (diagnosed by histological investigation) underwent a 20-min hypoxic perfusion of the isolated abdominal compartment with 20 mg/m2 mitomycin C (MitomedacTM, medac, Hamburg, Germany) 22 times. Cytostatic concentration was determined intrainterventionally within the systemic and regional compartment. Results: The mitomycin C concentration was 10 times higher within the regional compared with the systemic compartment at its maximum. The area under the curve was 4.02 times greater. Toxicity was considerable, i.e. WHO grade I/II in 8 of 17 cases, and III/IV in 9 of 17 cases. Two treatment-related deaths were documented. The objective response rate was 17.6% (3 of 17 cases; 1 complete remission, 2 partial remissions). In 3 subjects, stable disease was registered, and in 11 individuals, tumor progression. The median survival was 4.1 months. Conclusion: Though high concentrations of the cytostatic drug were achieved within the regional compartment, the aortic stop flow technique was associated with a high toxicity rate but no improvement of tumor response and survival in comparison with systemic chemotherapy. Despite its pharmacokinetic advantages, the aortic stop flow technique is currently not recommendable for routine use.

Background: In advanced pancreatic carcinoma, no effective chemotherapy has been found yet due to the lack of appropriate response. The frequent use of gemcitabine is based on the fact that there is a significant improvement in the quality of life, but neither an effect on remission nor a detectable increase in survival rates could be observed. Therefore, the hypothesis was that the combination of gemcitabine with other drugs can result in a better outcome of patients. The aim of this study was to determine the maximally tolerable dosage of gemcitabine and docetaxel using a weekly administration regimen. Patients and Methods: Twenty-five patients with advanced or metastatic pancreatic carcinoma received combination chemotherapy using gemcitabine and docetaxel in a weekly administration regimen, beginning with 800 mg/m2 of gemcitabine and 25 mg/m2 of docetaxel. Four patients were originally enrolled for each of the seven different dosages of both drugs. Side effects were assessed according to the WHO standard. Quality of life was evaluated according to the Core Quality of Life Questionnaire (QLQ-C30) of the European Organization for Research and Treatment of Cancer. Results: Using the two maximal dosages of gemcitabine and docetaxel (gemcitabine, 800 and 1,000 mg/m2, and docetaxel, 45 and 40 mg/m2; respectively), only 3 and 2 patients were enrolled, respectively, because of toxic side effects ≧ grade III according to WHO grading. Maximal dosages with tolerable side effects were 1,000 mg/m2 of gemcitabine and 35 mg/m2 of docetaxel given in weekly intervals. Main side effects of this combination chemotherapy were gastrointestinal symptoms and hematologic toxicity. Conclusion: Combination therapy with gemcitabine and docetaxel in advanced or metastatic pancreatic carcinoma is a well-tolerated and acceptable alternative treatment option with regard to the severity of side effects and its positive impact on quality of life and tumor-associated pain. According to the study endpoint, dosages of 1,000 mg/m2 of gemcitabine and 35 mg/m2 of docetaxel are recommended as maximum-tolerated doses (given in weekly intervals) for a future phase II trial.

Palliative treatment is often the only remaining option in the management of pancreatic carcinoma, but its efficacy is poor due to low tumor sensitivity and inadequate treatment protocols. There are several options of palliative treatment with antitumor or supportive intention. Classical end points of palliative treatment are survival, tumor response, and quality of life. A decade ago, palliative chemotherapy consisted mainly of 5-fluorouracil as the standard agent in combination with either other agents and/or radiotherapy. Only the new antineoplastic drug gemcitabine, which was introduced simultaneously with the definition of novel end points of chemotherapy such as clinical benefit, allowed to achieve some progress. However, while gemcitabine monotherapy appeared to be superior to 5-fluorouracil and improved important parameters of quality of life, it could not provide a significant improvement of survival. A novel concept, therefore, is to improve this beneficial cytostatic response in pancreatic carcinoma using a gemcitabine-based protocol by combining it with antineoplastic drugs such as taxanes or platin analogs. This strategy may have the potential to improve the outcome in palliative chemotherapy of pancreatic carcinoma patients with advanced tumor growth or metastases. Best supportive care in pancreatic cancer consists of the treatment of symptoms, such as pain, jaundice, duodenal obstruction, weight loss, exocrine pancreatic insufficiency, and tumor-associated depression.

Background : The biochemical rationale for the use of folinic acid (FA) and interferon (IFN) to modulate and thereby enhance the antitumor activity of 5-fluorouracil (5-FU) in vitro

Although for patients with Crohn’s disease a significantly higher incidence of liver abscesses has been theoretically calculated than for patients of the general population, there are only 30 cases re

A case of adenocarcinoma arising in a choledochal cyst (type I in the Todani classification) 23 years after enteric drainage is presented. A complete resection of the choledochal duct with the choledo

Randomized studies proved the efficacy of new drugs for the systemic treatment of advanced gastric cancer in the past 5 years. However, little is known about the use of firstline chemotherapy in clinical practice in patients with advanced or metastatic adenocarcinoma of the esophagogastric junction (AEG) and the stomach. We investigated temporal trends in therapy and factors influencing treatment decisions for these patients during a 4-year period.1058 patients (median age 67 years) with advanced AEG or gastric cancers undergoing treatment decisions were documented with the Therapiemonitor® in 2006-2009. Therapiemonitor collects population-based data regarding treatment decisions and strategies. Time trends of drug use and intensity in the first-line treatment were analyzed in the entire patient group and according to age (cut-off 65 years) and Karnofsky performance status (KPS; cut-off 80%).Over time, the use of oxaliplatin and docetaxel as well as capecitabine increased while cisplatin and irinotecan use slightly declined. The use of chemotherapy triplets rose from 10.1% in 2006 to 47.0% in 2009. Treatment patterns significantly varied by age and KPS: Older patients were significantly less likely to receive chemotherapy triplets, cisplatin and docetaxel but tended to more often receive oxaliplatin. Likewise, triplets, cisplatin and docetaxel were less frequently used in patients with KPS80%, while capecitabine and irinotecan were significantly more often used in this patient group.A clear tendency towards the use of more intensive chemotherapy regimens in patients with AEG and gastric cancer was observed over time. Older or less fit patients were treated preferably with monotherapy or chemotherapy doublets during 2006-2009. Oxaliplatin and docetaxel use has substantially risen.