Is a surgical approach justified for octogenarians with pancreatic carcinoma? Projecting surgical decision making for octogenarian patients

Background

In recent years, more elderly patients have undergone surgery for pancreatic cancer, although the safety and efficacy of performing complex pancreatic resections in patients older than 80 years remain controversial.

Methods

Patients with pancreatic cancer who underwent curative surgical treatment were divided into 2 subgroups: the younger group (<80 years) and the octogenarian group (≥80 years).

Results

From March 2005 to December 2013, 194 consecutive surgically curable patients with diagnosed pancreatic cancer were studied, among which 34 (17.5%) were of 80 years or older. There were no significant differences in postoperative severe complication rates for younger and octogenarian groups (16% vs 20%, respectively) or perioperative mortality rates (1.3% vs .0%). The incidence of postoperative delirium in the octogenarian group was greater than that in the younger group (23.5% vs 3.8%).

Conclusions

Octogenarian pancreatic cancer patients should not be denied a priori the opportunity for surgery, particularly if the patient represents an ideal candidate and if the co-operation of the family can be obtained.     

Effectiveness of intensive follow-up after response in patients with small cell lung cancer

We investigated whether intensive follow-up leads to earlier diagnosis of recurrence, more effective treatment, and longer survival in patients with small cell lung cancer (SCLC) who had shown a complete or partial response to first-line chemotherapy. The subjects of this retrospective study were 94 patients with SCLC who had shown a complete or partial response to first-line chemotherapy. The patients were separated into two arms: an intensive follow-up arm in which patients underwent regular blood tests, chest radiography, computed tomography of the chest and upper abdomen, magnetic resonance or computed tomography of the brain, and bone scintigraphy bimonthly for 6 months and then quarterly for 1.5 years; and a nonintensive follow-up arm in which these examinations were performed at the physician's discretion. All patients also underwent interviews and physical examinations monthly for 2 years and bimonthly for a further 3 years. Patient characteristics did not differ significantly between the arms. Disease recurred in 55 of 62 patients of the intensive arm and 29 of 32 patients of the nonintensive arm. Asymptomatic recurrences were detected more frequently in the intensive arm than in the nonintensive arm. The response rate to salvage therapy among all patients with recurrent disease was significantly higher in the intensive arm (61.8%) than in the nonintensive arm (37.9%; p=0.04). Both median postrelapse survival and overall median survival were significantly longer in the intensive arm (9 and 20 months, respectively, p=0.04 and p=0.001) than in the nonintensive arm (4 and 13 months, respectively). Intensive follow-up helps detect recurrence earlier, enhances the effectiveness of treatment, and lengthens survival in patients with SCLC. Well-designed prospective, randomized trials including a cost-benefit analysis are needed to compare intensive and nonintensive follow-up regimens.     

Phase II trial of the combination of carboplatin and irinotecan in elderly patients with small-cell lung cancer

Aim

The aim of the present phase II study was to assess the antitumour activity and safety of the combination of irinotecan and carboplatin in elderly patients with small-cell lung cancer (SCLC).

Material and methods

Patients with previously untreated SCLC were eligible if they had a performance status of 0-2, were 70 years or older, and had adequate organ function. Patients were treated with carboplatin at an area under the plasma concentration versus time curve of 5 min/ml on day 1 and with irinotecan at 50 mg/m² on days 1 and 8 every 3 weeks.

Results

Thirty patients (26 men and 4 women; median age, 76 years; age range, 70-86 years) were enrolled. Eight patients had limited disease (LD) and 22 patients had extensive disease (ED). The overall response rate was 83.3% (95% confidence interval: 65.3-94.4%). Response rates did not differ significantly between patients with LD (87.5%) and those with ED (81.8%; p = 0.71). The median survival time was 14 months overall and was significantly longer in patients with LD (26 months) than in patients with ED (11 months; p = 0.025). The median progression free survival time was 6 months overall and was significantly longer in patients with LD (12 months) than in patients with ED (6 months; p = 0.016). Grade 3-4 toxicities included neutropenia in 83% of patients, thrombocytopenia in 47%, anaemia in 60%, infection in 23%, and diarrhoea in 20%. There were no treatment-related deaths.

Conclusions

This chemotherapy is safe and effective for elderly patients with SCLC.     

Resected cystadenoma of the common bile duct

Biliary cystadenoma in the extrahepatic bile ducts is a very rare tumor. A 62-year-old woman with jaundice was admitted to our hospital. Imaging studies revealed a 4-cm cystic lesion around the hepatic hilum, compressing the common bile duct (CBD). When laparotomy was performed, a cystic tumor was detected in the hepatic hilum, filling the lumen of the CBD. Bile duct resection that included the tumor was performed, followed by biliary reconstruction. Microscopically, the cyst wall was lined by a single layer of cuboidal epithelial cells, covering an ovarian-like stroma. The degree of atypia was low and warranted the diagnosis of cystadenoma.     

Preliminary clinical evaluation of continuous infusion of 5-FU and low-dose Cisplatin (LFP) therapy alone and combined with radiation therapy for treatment of advanced or recurrent esophageal cancer

We evaluated the clinical effect of 5-FU and low-dose Cisplatin (LFP) therapy alone and LFP therapy combined with radiation therapy in patients with advanced or recurrent esophageal cancer. From March 1995 to September 2000, 11 patients with inoperable esophageal cancer, 8 patients with adjuvant chemotherapy post operation, and 14 patients with recurrent esophageal cancer were treated with LFP therapy. 5-FU (160 mg/m2/day) was continuously infused over 24 hours, and CDDP (3-7 mg/m2/day) was infused for 30 minutes. The administration schedule consisted of 5-FU for 7 consecutive days and CDDP for 5 days followed by a 2-day rest, each for four weeks. We combined radiation therapy for the patients with all lesions that could be included in the radiation field. Of 30 patients with measurable lesions the response rates of LFP therapy alone and LFP therapy combined with radiation therapy were 33% and 60%, respectively. Toxicity over grade 3 appeared in 3 of 15 patients with LFP therapy combined with radiation therapy. There was no significant difference between LFP therapy alone and LFP therapy combined with radiation therapy with regard to survival rate of inoperable and recurrent esophageal cancer. In conclusion, LFP therapy alone may be effective for esophageal cancer.     

Peripheral insertion of a central venous access device under fluoroscopic guidance using a Peripherally Accessed System (PAS) port in the forearm

Purpose: We describe the technique, efficacy, and complications of fluoroscopy-guided implantation of a central venous access device using a peripherally accessed system (PAS) port via the forearm. Methods: Beginning in July 1994, 105 central venous access devices were implanted in 104 patients for the long-term infusion of antibiotics or antineoplasmic agents, blood products, or parenteral nutrition. The devices was inserted under fluoroscopic guidance with real-time venography from a peripheral route. Results: All ports were successfully implanted. There were no procedure-related complications. No thrombosis or local infection was observed; however, in six patients catheter-related phlebitis occurred. Conclusion: Fluoroscopy-guided implantation of a central venous access device using a PAS port via the forearm is safe and efficacious, and injection of contrast medium through a peripheral IV catheter before introduction of the catheter helps to avoid catheter-related phlebitis.     

Removal of a catheter mount and heat-and-moisture exchanger improves hypercapnia in patients with acute respiratory distress syndrome: A retrospective observational study

To avoid ventilator-associated lung injury in acute respiratory distress syndrome (ARDS) treatment, respiratory management should be performed at a low tidal volume of 6 to 8 mL/kg and plateau pressure of ≤30 cmH₂O. However, such lung-protective ventilation often results in hypercapnia, which is a risk factor for poor outcomes. The purpose of this study was to retrospectively evaluate the effectiveness and safety of the removal of a catheter mount (CM) and using heated humidifiers (HH) instead of a heat-and-moisture exchanger (HME) for reducing the mechanical dead space created by the CM and HME, which may improve hypercapnia in patients with ARDS.This retrospective observational study included adult patients with ARDS, who developed hypercapnia (PaCO₂ > 45 mm Hg) during mechanical ventilation, with target tidal volumes between 6 and 8 mL/kg and a plateau pressure of ≤30 cmH₂O, and underwent stepwise removal of CM and HME (replaced with HH). The PaCO₂ values were measured at 3 points: ventilator circuit with CM and HME (CM + HME) use, with HME (HME), and with HH (HH), and the overall number of accidental extubations was evaluated. Ventilator values (tidal volume, respiratory rate, minutes volume) were evaluated at the same points.A total of 21 patients with mild-to-moderate ARDS who were treated under deep sedation were included. The values of PaCO₂ at HME (52.7 ± 7.4 mm Hg, P < .0001) and HH (46.3 ± 6.8 mm Hg, P < .0001) were significantly lower than those at CM + HME (55.9 ± 7.9 mm Hg). Measured ventilator values were similar at CM + HME, HME, and HH. There were no cases of reintubation due to accidental extubation after the removal of CM.The removal of CM and HME reduced PaCO₂ values without changing the ventilator settings in deeply sedated patients with mild-to-moderate ARDS on lung-protective ventilation. Caution should be exercised, as the removal of a CM may result in circuit disconnection or accidental extubation. Nevertheless, this intervention may improve hypercapnia and promote lung-protective ventilation.