Second-line Palliative Chemotherapy Research Articles

Real-world outcomes of metastatic clear cell sarcoma sequential chemotherapy

Clear cell sarcoma is an ultra-rare chemoresistant subtype of soft tissue sarcoma. This retrospective analysis aimed to clarify the efficacy of palliative chemotherapy in CCS by assessing response rates, progression-free survival (PFS), and overall survival (OS) at a referral center. A retrospective analysis of palliative treatment was conducted on patients with CCS treated at the sarcoma unit from 1997 to 2023. Treatment responses were assessed using RECIST criteria, and the Kaplan–Meier method was used to calculate PFS and OS. The analysis covered 23 CCS chemotherapy-treated patients with 11 (47.8%) men. The median age at the palliative treatment start was 32 years (range 18-59). The median follow-up was 8.2 months. Four patients were referred to our centre for M1 disease, and 6 received perioperative chemotherapy and progressed during follow-up. In the first line, 14 patients received anthracycline-based chemotherapy (60.9%), five were treated with ifosfamide (HD-IFO), and four received other regimens. One patient (4.3%) achieved partial response (PR), and 12 patients (52.2%) achieved stable disease (SD) as the best response. Median PFS in 1 line was 2.79 months (95% CI: 2.04–8.38), and 1.76 months (95% CI: 0.72–6.97) in the second line. The median OS from first-line palliative chemotherapy was 8.2 months (95% CI: 6.2–14), and the second-line palliative chemotherapy mOS was 4.6 months (95% CI: 3.9–NA). Perioperatively anthracycline-pretreated worsened patients’ median PFS in the M1 setting. Poor responses to conventional chemotherapy were observed in CCS, indicating a need for further clinical trials in this indication.

Real-world outcomes of metastatic clear cell sarcoma sequential chemotherapy

Clear cell sarcoma is an ultra-rare chemoresistant subtype of soft tissue sarcoma. This retrospective analysis aimed to clarify the efficacy of palliative chemotherapy in CCS by assessing response rates, progression-free survival (PFS), and overall survival (OS) at a referral center. A retrospective analysis of palliative treatment was conducted on patients with CCS treated at the sarcoma unit from 1997 to 2023. Treatment responses were assessed using RECIST criteria, and the Kaplan–Meier method was used to calculate PFS and OS. The analysis covered 23 CCS chemotherapy-treated patients with 11 (47.8%) men. The median age at the palliative treatment start was 32 years (range 18-59). The median follow-up was 8.2 months. Four patients were referred to our centre for M1 disease, and 6 received perioperative chemotherapy and progressed during follow-up. In the first line, 14 patients received anthracycline-based chemotherapy (60.9%), five were treated with ifosfamide (HD-IFO), and four received other regimens. One patient (4.3%) achieved partial response (PR), and 12 patients (52.2%) achieved stable disease (SD) as the best response. Median PFS in 1 line was 2.79 months (95% CI: 2.04–8.38), and 1.76 months (95% CI: 0.72–6.97) in the second line. The median OS from first-line palliative chemotherapy was 8.2 months (95% CI: 6.2–14), and the second-line palliative chemotherapy mOS was 4.6 months (95% CI: 3.9–NA). Perioperatively anthracycline-pretreated worsened patients’ median PFS in the M1 setting. Poor responses to conventional chemotherapy were observed in CCS, indicating a need for further clinical trials in this indication.

Comparing effectiveness and safety of paclitaxel plus raltitrexed vs. paclitaxel alone in second-line palliative chemotherapy for metastatic gastric adenocarcinoma: A randomized phase II clinical trial.

Paclitaxel (P) is a standard second-line chemotherapy in the treatment of advanced gastric cancer. This study compared the clinical outcome of a paclitaxel plus raltitrexed (RP) regimen as second-line treatment in metastatic gastric cancer (MGC) patients. An open, randomized, multi-center phase II clinical trial was conducted involving 148 patients who were randomly assigned and treated with RP [raltitrexed (3 mg/m2 on day 1) and paclitaxel (135 mg/m2 on day 1 every 3 weeks)] or P [paclitaxel (135 mg/m2 on day 1 every 3 weeks)] as 2nd-line chemotherapy. The primary endpoint was progression-free survival (PFS). The secondary endpoints were the overall response rate (ORR), overall survival (OS), and safety. PFS had a tendency to be prolonged with RP compared to P (2.7 months vs. 1.7 months; P = 0.148). OS was also prolonged with RP compared to P (10.2 months vs. 6.1 months; P = 0.140). The ORR was equal in the RP and P groups (6.8% and 4.0%; P = 0.72). The disease control rate (DCR) in the RP and P groups was 56.2% and 36.0%, respectively. Grade 3-4 treatment-related adverse events occurred in 36.2% (RP) and 28.2% (P) of patients. Frequent grade 3-4 toxicities for RP and P were neutropenia (11.0% and 4.0%), anemia (1.4% and 4.0%), and thrombocytopenia (1.4% and 5.3%), and all grades of peripheral neurotoxicity (12.3% vs. 17.3%). All grades of hepatic toxicity were demonstrated for the RP and P groups based on elevated aminotransferase levels (27.4% and 14.1%). Subgroup analysis shows if MGC was combined with ascites or peritoneal involvement, the OS of the RP regimen was longer (P = 0.05). Second-line palliative chemotherapy with RP was shown to prolong the PFS and OS, especially among patients with ascites or peritoneal involvement, which warrants confirmation using larger sample studies.

C-reactive protein/albumin ratio is the most significant inflammatory marker in unresectable pancreatic cancer treated with FOLFIRINOX or gemcitabine plus nab-paclitaxel

There are limited absolute biomarkers for determining the prognosis before first- and second-line palliative chemotherapy in unresectable pancreatic cancer (urPC) patients. To find the best prognostic inflammatory marker, we investigated relationships between overall survival (OS) and six inflammatory markers; C-reactive protein/albumin ratio (CAR), neutrophil–lymphocyte ratio (NLR), prognostic nutrition index (PNI), platelet–lymphocyte ratio (PLR), Glasgow prognostic score (GPS), and prognostic index (PI). We examined 255 patients who received gemcitabine + nab-paclitaxel or FOLFIRINOX as first-line chemotherapy and 159 patients who subsequently underwent second-line chemotherapy. First-line patients with lower CAR had better OS compared to those with a higher CAR (hazard ratio 0.57; 95% confidential index 0.42–77; P < 0.01). Similarly, lower NLR (P = 0.01), higher PNI (P = 0.04), lower PLR (P = 0.03), GPS score of 0 (P < 0.01) and PI score of 0 (P < 0.01) were all associated with better OS. CAR demonstrated the best superiority for determining survival prognosis through the use of area under the curve of time-dependent receiver-operating characteristic curves. Furthermore, a lower CAR before second-line therapy exhibited better OS versus higher CAR (P < 0.01). Therefore, CAR might be a useful biomarker for predicting urPC patient prognosis in both first- and second-line chemotherapy.

Hemoglobin and Neutrophil Count as Prognostic Factors in Cholangiocarcinoma Patients in 2nd Line Treatment Setting: Results from a Small Monocentric Retrospective Study.

Unresectable cholangiocarcinoma prognosis can be extremely variable due to different symptoms and sites of disease involvement at diagnosis and unpredictable chemotherapy response rates. Most patients will usually receive 1st line palliative chemotherapy with platinum compounds and Gemcitabine or Gemcitabine alone. Only a few patients maintain adequate performance status after first-line treatment failure: second-line treatment with FOLFOX or FOLFIRI chemotherapy has been used in this setting with modest overall survival improvement. There is a lack of data concerning whether laboratory findings might help clinicians in identifying those patients with the highest likelihood of benefiting from 2nd line treatment. The aim of this analysis is to assess the prognostic role of a series of easily available laboratory tests in patients with bile duct cancer who received 2nd line chemotherapy. Patients with unresectable bile duct cancer treated in 2nd-line setting with platinum-based chemotherapy doublet or FOLFIRI were enrolled. The primary objective of the analysis was to assess overall survival (OS) differences among patients based on the results of lab tests. Serum hemoglobin, neutrophil, lymphocyte, monocyte, platelet absolute count, creatinine, total bilirubin, albumin, LDH, circulating CEA and CA19.9 values were collected at the start of 2nd line treatment. Cut-off values for all lab tests were set by ROC curve analysis. Survival was calculated by the Kaplan-Meier method and differences in survival among stratification factors were assessed by Log-rank test. Cox-proportional-hazard regression was used for multivariate analysis. Level of statistical significance p was set at 0.05 for all tests. Correction for false discovery error rate was performed by Holm's stepdown procedure. A total of 46 patients were eligible. Median overall survival of the entire cohort was 8.98 months (95%CI: 6.68-13.93) while mean OS was 17.10 months (standard error: 3.16). Using 6.2 months OS landmark as classification variable for ROC curve analysis, only serum hemoglobin (cut-off: &gt;10 g/dL), albumin (cut-off: &gt;3.5 mg/dL), CA19.9 (cut-off: ≤668 UI/mL), monocyte (cut-off: ≤510/mmc) and neutrophil count (cut-off: ≤5140/mmc) were significantly associated with the chosen end-point. Multivariate analysis confirmed an independent statistically significant impact on overall survival only for hemoglobin (Exp(b): 0.12, p = 0.0023) and neutrophil count (Exp(b): 0.30, p = 0.0039). Based on these results, using both hemoglobin and neutrophil count, three prognostic groups were defined: patients with both favorable factors had 12.63 months median OS vs. 6.75 months of patients with only one favorable factor vs. 1.31 months of those with neither. The difference between these three groups of patients was statistically significant (p &lt; 0.0001). Second-line palliative chemotherapy can be a potentially useful option for a few patients with unresectable/metastatic bile duct cancer. Even though assessment of patients' prognosis might be difficult due to the complex behavior of this disease, a series of easily available laboratory tests might be used for these means: serum hemoglobin and neutrophil count we0re able to define subsets of patients with entirely different prognoses. It is hoped that this score will be prospectively validated in a larger group of patients in order to improve treatment decisions in patients with unresectable bile duct cancer candidate to receive palliative 2nd line chemotherapy.

Impact of mismatch repair or microsatellite status on the prognosis and efficacy to chemotherapy in metastatic colorectal cancer patients: A bi-institutional, propensity score-matched study.

Background: Deficient mismatch repair (dMMR) or the microsatellite instability (MSI) phenotype occupied approximately 15-18% of CRC patients. Previous studies showed that dMMR/MSI status is a favorable prognostic factor for stage II/III CRC patients. For metastatic colorectal cancer (mCRC) patients, only 5% of patients have the dMMR/MSI-H phenotype. The relationship between dMMR/MSI, chemosensitivity and survival in mCRC patients of real-world is still not clear.Materials and methods: In this study, we enrolled 77 dMMR/MSI-H mCRC patients and compared their clinicopathological characteristics with those of 510 proficient MMR (pMMR) or microsatellite stable (MSS) mCRC patients. With propensity score matching (PSM) analysis, we further compared the chemosensitivity and survival of dMMR/MSI-H mCRC patients with pMMR/MSS patients. We also analyzed the efficacy of different chemotherapy and target therapy in the dMMR/MSI-H population.Results: In PSM cohort, the objective response rate (ORR) of mCRC patients with dMMR/MSI-H undergoing first-line palliative chemotherapy was 35.2%, which was similar with patients with pMMR/MSS (35.4%, p = 1.00). The median progression-free survival (PFS) of first-line chemotherapy was significantly different (dMMR/MSI-H vs pMMR/MSS = 7.4 months vs 10.2 months; HR = 0.74; 95%CI, 0.57-0.98; p = 0.03). Overall survival (OS) of patients did not significantly differ by status (dMMR/MSI-H vs pMMR/MSS = 40.0 months vs 41.3 months; HR = 1.09; 95%CI, 0.74-1.59; p = 0.68). For second-line palliative chemotherapy, there was no difference in ORR (p = 0.53) or in PFS (HR = 0.88; 95%CI, 0.59-1.33; p = 0.56) between dMMR/MSI-H and pMMR/MSS tumors. We also found that in the overall cohort, the ORR of patients who received oxaliplatin-based and irinotecan-based chemotherapy were 28.8% and 54.5%, respectively, which were not significantly different (p = 0.16). Our results also showed that the use of bevacizumab could lead to a significantly higher ORR in dMMR/MSI-H mCRC patients compared to chemotherapy alone (55.0% vs 22.2%; p = 0.02), whereas cetuximab could not.Conclusion: The dMMR/MSI-H is not a prognostic factor for mCRC patients but is correlated with shorter PFS to first-line palliative chemotherapy.

Real-world evidence on first- and second-line palliative chemotherapy in advanced pancreatic cancer.

In spite of recent diagnostic and therapeutic advances, the prognosis of pancreatic ductal adenocarcinoma (PDAC) remains very poor. As most patients are not amenable to curative intent treatments, optimized palliative management is highly needed. One key question is to what extent promising results produced by randomized controlled trials (RCTs) correspond to clinically meaningful outcomes in patients treated outside the strict frames of a clinical trial. To answer such questions, real-world evidence is necessary. The present paper reviews and discusses the current literature on first- and second-line palliative chemotherapy in PDAC. Notably, a growing number of studies report that the outcomes of the two predominant first-line multidrug regimens, i.e. gemcitabine plus nab-paclitaxel (GnP) and folfirinox (FFX), is similar in RCTs and real-life populations. Outcomes of second-line therapy following failure of first-line regimens are still dismal, and considerable uncertainty of the optimal management remains. Additional RCTs and real-world evidence studies focusing on the optimal treatment sequence, such as FFX followed by GnP or vice versa, are urgently needed. Finally, the review highlights the need for prognostic and predictive biomarkers to inform clinical decision making and enable personalized management in advanced PDAC.

Second-line palliative chemotherapy, survival, and prognostic factors in patients with advanced pancreatic cancer

Introduction Pancreatic cancer is a highly lethal disease with a close association between incidence and mortality. First-line (FL) palliative chemotherapy prolongs survival and alleviates cancer-related symptoms. However, the survival benefit of second-line (SL) treatment is uncertain, as studies fail to consistently show prolonged survival for any given SL treatment, and in the absence of prognostic factors patients will receive a futile treatment. The aim of this study was to examine prognostic factors and survival in patients with pancreatic cancer, with special reference to SL therapy. Material and methods This retrospective study included all patients with histopathologically verified pancreatic adenocarcinoma who received palliative chemotherapy at Skåne University Hospital and died between 1 Feb 2015 and 31 Dec 2017. Results During the study period, a total of 170 patients with pancreatic cancer died after receiving palliative chemotherapy. Of these, 72 had received SL treatment after progression on FL treatment. Median overall survival (OS) from the start of SL treatment was 5.0 months (95% CI: 4.0–6.1). Median OS was 2.9 months for patients with performance status 2 at start of SL treatment compared to 5.3 months for patients with performance status 0–1 (p = .03), and 3.5 months (95% CI: 3.0–5.4) in patients with hypoalbuminemia (<36 g/L) at the start of SL therapy compared to 8.0 months (95% CI: 5.3–11.1) for patients with normal albumin levels (p = .009). Weight loss during FL therapy, a doubling of CA 19-9 after FL therapy, and length of progression-free survival during FL treatment were not associated with survival following SL therapy. Conclusion Poor performance status and hypoalbuminemia are negative prognostic factors for survival on SL palliative treatment in patients with advanced pancreatic cancer. Possible gain in survival should be carefully considered before initiating SL chemotherapy.

Real World Evidence on Second-Line Palliative Chemotherapy in Advanced Pancreatic Cancer

Background: The outcome and tolerability of palliative second line chemotherapy for advanced pancreatic cancer (APC) in real life patients are largely unknown. Prognostic parameters for risk stratification and treatment guidance are lacking.Materials and Methods: A population based multicenter retrospective cohort study was conducted, covering all APC patients who received palliative second-line chemotherapy between 2011 and 2018 at any cancer center in the South East Region of Sweden. Primary outcome was overall survival after second-line therapy (OS2). Time to treatment failure after second-line therapy (TTF2), hematological toxicity, and unplanned hospitalizations were key secondary outcomes. A number of baseline potentially prognostic parameters were assessed.Results: A total of 509 patients received first-line palliative chemotherapy, and of these 167 (33%) received at least one dose of second-line therapy and formed the final study population. Median OS2 was 5.2 months (95% CI = 4.7–5.7) and median TTF2 was 1.9 months (1.5–2.2). OS2 and TTF2 were similar regardless regimen, including comparison of the two most common regimens (fluoropyrimidine monotherapy vs. fluoropyrimidine/oxaliplatin doublet). Multivariate analysis revealed that normal plasma albumin (≥35) and serum CA-19-9 above median (>1,550) were independent predictors for OS2 (HR = 0.21, p < 0.001 and HR = 2.03, p = 0.009) and TTF2 (HR = 0.22, p < 0.001 and HR = 2.03, p = 0.01), while ECOG performance status >1 was predictive for TTF2 (HR = 2.05, p = 0.032). Grade 3–4 hematological toxicity was registered in 17 patients (10%). 50 (30%) had at least one event of hospitalization.Conclusion: The real world outcome of second line palliative chemotherapy for refractory APC remains dismal. Baseline plasma albumin, serum CA-19-9, and performance status emerge as key prognostic factors, and should be further studied as tools for individualized treatment decisions.

Cost-effectiveness analysis of pressurized intraperitoneal aerosol chemotherapy (PIPAC C/D) in patients with gastric cancer and peritoneal metastasis.

387 Background: The efficacy of systemic chemotherapy is still highly unsatisfactory for patients with gastric cancer and peritoneal metastases (PM). The aim of this study was to assess the costs effectiveness of pressurized intraperitoneal aerosol chemotherapy with low-dose cisplatin and doxorubicin (PIPAC C/D) for advanced gastric cancer. Methods: We developed a state transition Markov Model to estimate the costs and effectiveness of the use of PIPAC C/D versus palliative chemotherapy. Intervention was assessed in two different levels including upfront therapy (PIPAC C/D plus XELOX chemotherapy versus first-line chemotherapy alone) and second line therapy (PIPAC C/D only versus second-line chemotherapy (ramucirumab monotherapy)). Data from multiple sources such as published literature and UK-based databases were used to inform the economic model. Deterministic and probabilistic sensitivity analyses were conducted to explore the impact of key parameter variation on the results. Results: For the upfront therapy the estimated total costs in the intervention and comparator arms were £33,587(SD: £2,394) and £17,477 (£927) respectively. PIPAC C/D plus XELOX led to an increase of 0.56 in QALYs. Estimated incremental cost per quality adjusted life years (QALYs) was £28,879. Result from probabilistic sensitivity analysis showed that PIPAC C/D plus XELOX is cost effective in more than 50% of Monte Carlo simulations at £30,000 threshold. For the second-line therapy, the total costs for PIPAC C/D was £15,985 (£1,391) and for the second-line palliative chemotherapy was £36,319 (£3,673). PIPAC C/D led to an increase of 0.21 in QALYs and £20,222 reduction in costs, meaning the intervention is dominant strategy in the second line therapy as it is less costly and more effective. Conclusions: The cost effectiveness results for the upfront therapy indicate that PIPAC C/D plus chemotherapy intervention is more costly and more effective and a cost effective intervention. PIPAC C/D only intervention has the potential to reduce costs and improve clinical outcomes for patients with advanced gastric cancer with peritoneal metastasis and therefore a dominant strategy.

Single-Center Experience with Ifosfamide Monotherapy as Second-Line Treatment of Recurrent/Metastatic Osteosarcoma.

BackgroundThe effectiveness of second‐line palliative chemotherapy in patients with recurrent/metastatic osteosarcoma is not well defined. Several small studies (6–19 patients) have reported on ifosfamide as second‐line treatment. In this study we report our single‐center experience with second‐line ifosfamide monotherapy in patients treated for recurrent/metastatic osteosarcoma.MethodsA chart review was conducted of all patients with osteosarcoma treated with ifosfamide from 1978 until 2017. Until 1997 a 5 g/m2 regimen was used, and from 1997 onwards a 9 g/m2 regimen was used. Overall survival (OS) from start of ifosfamide was the primary endpoint. Progression‐free survival (PFS) from start of treatment was also studied. To assess difference in survival between groups the log rank test was applied. To investigate the effect of ifosfamide dose and World Health Organization performance status (PS) a Cox proportional hazard regression model was estimated.ResultsSixty‐two patients were selected with recurrent/metastatic osteosarcoma treated with second‐line ifosfamide monotherapy (dose of 5 g/m2, n = 26; 9 g/m2, n = 36). OS was significantly better in univariate analysis for 9 g/m2 compared with 5 g/m2 (10.9 months [95% confidence interval (CI), 9.3–12.6] vs. 6.7 months [95% CI, 5.9–7.6], respectively) and for PS (median OS PS 0, 13.0 months [95% CI, 2.3–23.8]; PS 1, 8.2 months [95% CI, 5.4–11.1]; PS ≥2, 6.2 months [95% CI, 2.2–10.3]; and unknown PS, 5.4 months [95% CI, 2.2–8.5]). In multivariate analysis only PS showed a significant difference. No difference in PFS was found between 5 and 9 g/m2 ifosfamide treatment or PS.ConclusionThis study suggests that ifosfamide is an effective second‐line treatment for patients with recurrent/metastatic osteosarcoma.Implications for PracticeIfosfamide monotherapy is commonly used as second‐line treatment in osteosarcoma, although large series to support this are lacking. This retrospective study reports overall and progression‐free survival for regimens with 5 g/m2 and with 9 g/m2. This study was unable to show a significant difference in survival between 5 and 9 g/m2 but showed an important impact of World Health Organization performance status on overall survival. This study sets a standard and reference for comparison with the multiple phase II studies under development.

Comparison of efficacy and safety of second-line palliative chemotherapy with paclitaxel plus raltitrexed and paclitaxel alone in patients with metastatic gastric adenocarcinoma: A randomized phase II trial.

4054 Background: Paclitaxel is a microtubule stabilizing agent that has been the standard second line chemotherapy in the treatment of advanced gastric cancer. This study was designed to find out the clinical outcome of paclitaxel plus raltitrexed regimen as second line treatment in MGC patients. Methods: In an open, randomized, multi centers phase II clinical trial , 148 patients were randomly assigned and treated with either RP (raltitrexed 3 mg/m2 d1 and paclitaxel 135mg/m2 d1,3w) or P (paclitaxel 135mg/m2 d1,3w) as second-line palliative chemotherapy. The primary endpoint is PFS, secondary endpoint is ORR, OS and safety. Results: In 148 randomly assigned and treated patients (RP = 73; P = 75), the majority of patients were males (94 vs. 54). Progression free survival has a tendency to be prolonged with RP versus P (2.7m vs. 1.7m, p = 0.148). Overall survival also has a tendency to be prolonged with RP versus P (10.2m vs. 6.1m, p = 0.140). Overall response rate was equal with RP versus P (6.8% vs.4.0%, p = 0.72). DCR in the RP group was 56.2%, P group was 36.0%. Grade 3 to 4 treatment-related adverse events occurred in 36.2% (RP) v 28.2% (P) of patients. Frequent grade 3 to 4 toxicities for RP v P were: neutropenia (11.0% v 4.0%), anemia (1.4% v 4.0%), thrombocytopenia (1.4% v 5.3%), and all grade peripheral neurotoxicity (12.3% v 17.3%),all grade elevated aminotransferase (27.4% v 14.1%). Subgroup analysis shows if the disease combined with ascites or peritoneal involved , OS of RP regimen is more longer (p = 0.05). Conclusions: Second-line palliative chemotherapy with paclitaxel plus raltitrexed provides a tendency to prolong PFS and OS, and the patients with ascites or peritoneal involved may get benifits from combined chemotherapy, which needs to be confirmed by larger sample studies. Clinical trial information: NCT02072317.

Qualitative study of patients' decision-making when accepting second-line treatment after failure of first-line chemotherapy.

ObjectiveTreatment failures in advanced lung cancer are frequent events affecting patients during or after first-line chemotherapy. International guidelines recommend second-line chemotherapy. However, around one half of patients who experience disease progression enter a systemic second-line therapy. In the herein qualitative study, we investigated patients' thoughts and attitudes determining the decision to undergo a second-line chemotherapy.MethodsThirty-three purposively selected patients who recently accepted second-line or palliative chemotherapy were invited to participate in this survey consisting of semi-structured in-depth interviews. Grounded theory was applied to investigate participants’ perceptions of the context that have surrounded their decision to undergo palliative chemotherapy.ResultsFor most patients, tumor burden and reduced quality of life in relation with lung cancer itself were major drivers of the decision-making process. There was a balance between two different attitudes: making a decision to undergo a new line of chemotherapy or starting a psychological process in order to accept end of life. Choosing between these two attitudes allowed the patient to keep the matter of palliative care at a distance. Even in case of low chance of success, many patients who worried about their life partner's future would accept a new chemotherapy line. Some patients experienced ambivalent thoughts regarding social network, particularly about their family as daily function impairment required an increased need for relative's support. The initial "Worrying about others" thoughts left place to in an increasing self-need of care as those provided by relatives; this phenomenon might increase patients' self- perception of being a burden for others. Confidence previously established with formal caregiver support was another major decision driver: some patients with sustained confidence in their medical staff may have privileged this formal support rather than family support when the latter was perceived as weak, insufficient or intrusive.ConclusionThis study identified three domains involved into a complex interplay for lung cancer patients’ decision regarding second-line palliative chemotherapy: (i) perception of the definitive loss of health, (ii) interactions between idiosyncrasy (hope, disease burden) and environment (healthcare and social network support), and (iii) patient's subjective evaluation of chemotherapy benefit–risk.

Wet M1a non-small cell lung cancer: is it possible to predict recurrence of pleural effusion?

The propose was to recognize risk factors of malignant pleural effusion (MPE) recurrence in patients with symptomatic M1a non-small cell lung cancer (NSCLC). All patients with NSCLC and MPE submitted to pleural palliative procedures were enrolled in a prospective study. Group I contained patients who had pleural recurrence, and Group II with no pleural recurrence. Prognostic factors for pleural recurrence were identified by univariable analysis, using Fisher's exact test for categorical variables and Student's t test for quantitative variables. Afterwards the significant variables were entered into a multivariable logistic regression analysis (with P<0.05 considered significant). Receiver operating characteristics (ROC) analysis determined the cutoff points for continuous variables. A total of 82 patients were included in the analysis. There were 15 patients (18.3%) in Group I and 67 patients (81.7%) in Group II. Univariable analysis regarding factors affecting postoperative recurrence was: adenosine deaminase concentration in pleural fluid <16 mg/dL (P=0.04), albumin concentration in pleural fluid <2.4 mg/dL (P=0.03), administration of second-line palliative chemotherapy (P=0.018) and type of procedure [therapeutic pleural aspiration (TPA)] (P=0.023). At the multivariable analysis, only the type of procedure (TPA) (P=0.031) was identified as independent predictor of recurrence. The identification of this factor may assist the choice of the optimal palliative technique; at the first episode of MPE in NSCLC patients and definitive procedure as pleurodesis or indwelling pleural catheter are recommended.

Cutaneous metastasis of colon adenocarcinoma.

Skin metastasis originating from colorectal cancer is a rare entity and usually signifies poor prognosis. We present a case of a 62-year-old male patient who presented with a cutaneous metastatic focus on his forehead after five years of the primary treatment of colon cancer. Complete response from the cutaneous metastasis nodule was achieved with radiotherapy. The patient is still alive and under a second-line palliative chemotherapy regimen because of the multiple liver metastases. It is important for physicians to be aware of skin metastasis in patients with an oncology history.

Krukenberg Tumor in Pregnancy

An adnexal mass in pregnancy is a malignant tumor in 2–5% of cases. Ovarian cancer occurs in one in 8000 to one in 25,000 pregnancies. Krukenberg tumor is rare among ovarian metastases. They have a poor prognosis. This case report concerns a 25-year-old pregnant woman referred at 24 weeks of gestation with an ovarian tumor. MRI revealed malignant ovarian tumor with omental metastases. Staging laparotomy was done. Histology revealed metastatic adenocarcinoma with signet ring cells consistent with krukenberg tumor. It was later identified as primary colonic carcinoma based on immunohistochemistry since colonoscopy was unremarkable. In view of advanced stage, palliative chemotherapy was initiated. After completion of three cycles of chemotherapy, she went into preterm labor and delivered an alive baby vaginally at 32 weeks. Both mother and baby shifted to oncology on 10th postnatal day since postpartum imaging studies revealed a right ovarian mass, and she was started on second-line palliative chemotherapy. She did not have a favorable response and succumbed to the disease after five cycles of chemotherapy 4 months post-delivery. We present this case for its rare presentation during pregnancy, and early diagnosis would have had a better outcome.

Decision aids for second-line palliative chemotherapy: a randomised phase II multicentre trial

BackgroundThere is increasing recognition of the delicate balance between the modest benefits of palliative chemotherapy and the burden of treatment. Decision aids (DAs) can potentially help patients with advanced cancer with these difficult treatment decisions, but providing detailed information could have an adverse impact on patients' well-being. The objective of this randomised phase II study was to evaluate the safety and efficacy of DAs for patients with advanced cancer considering second-line chemotherapy.MethodsPatients with advanced breast or colorectal cancer considering second-line treatment were randomly assigned to usual care (control group) or usual care plus a DA (intervention group) in a 1:2 ratio. A nurse offered a DA with information on adverse events, tumour response and survival. Outcome measures included patient-reported well-being (primary outcome: anxiety) and quality of the decision-making process and the resulting choice.ResultsOf 128 patients randomised, 45 were assigned to the control group and 83 to the intervention group. Median age was 62 years (range 32-81), 63% were female, and 73% had colorectal cancer. The large majority of patients preferred treatment with chemotherapy (87%) and subsequently commenced treatment with chemotherapy (86%). No adverse impact on patients' well-being was found and nurses reported that consultations in which the DAs were offered went well. Being offered the DA was associated with stronger treatment preferences (3.0 vs. 2.5; p=0.030) and increased subjective knowledge (6.7 vs. 6.3; p=0.022). Objective knowledge, risk perception and perceived involvement were comparable between the groups.ConclusionsDAs containing detailed risk information on second-line palliative treatment could be delivered to patients with advanced cancer without having an adverse impact on patient well-being. Surprisingly, the DAs only marginally improved the quality of the decision-making process. The effectiveness of DAs for palliative treatment decisions needs further exploration.Trial registrationNetherlands Trial Registry (NTR): NTR1113 (registered on 2 November 2007)

OA21.05 Wet M1a Non-Small Cell Lung Cancer: Is It Possible to Predict Recurrence of Pleural Effusion?

Pleural and oncological treatment options for malignant pleural effusion (MPE) are increasing and hence, more accurate prognosis at presentation may help to identify patients with the higher risk of pleural recurrence, in order to individualize more intensive treatment strategies. The aim of this study was to identify predictors of malignant pleural effusion recurrence in patients with M1a non-small cell lung cancer (NSCLC). All patients with NSCLC and MPE submitted to pleural palliative procedures including simple pleural drainage, videothoracoscopic pleural drainage, pleurodesis and indwelling pleural catheter were enrolled in a prospective study between 2014 and 2015, and divided into two groups. Group I included patients who had pleural recurrence, and Group II with no pleural recurrence after the palliative procedures. Prognostic factors for pleural recurrence were identified by univariate analysis, using Fisher's exact test for the analysis of categorical variables and Student’s t test for quantitative variables. Subsequently the significant variables were entered into a multivariate logistic regression analysis (with p< 0.05 considered significant). The cutoff points for any significant continuous variables were determined by receiver operating characteristics (ROC) analysis. A total of 82 patients were included in the analysis. Median follow-up time for surviving patients was 81 days (range 1 to 1070 days). There were 15 patients (18.3%) in Group I and 67 patients (81.7%) in Group II. Univariate analysis of factors affecting postoperative recurrence were: adenosine deaminase concentration in pleural fluid < 16 mg/dl (p=0.04), albumin concentration in pleural fluid < 2.4 mg/dl (p= 0.03), administration of second-line palliative chemotherapy (p= 0.018) and type of procedure (simple pleural drainage vs. videothoracoscopic pleural drainage, pleurodesis and indwelling pleural catheter) (p= 0.023). At the multivariate analysis, only the type of procedure (simple pleural drainage)(p= 0.031) was identified as independent predictor of recurrence. In our cohort of NSCLC patients with MPE submitted to pleural palliative procedures, simple pleural drainage was the only significantly factor associated with recurrence of MPE. The identification of this factor may assist the choice of the optimal palliative technique, at the first episode of MPE in NSCLC patients. Definitive procedure as pleurodesis is recommended, the indwelling pleural catheter or videothoracoscopic drainage are options for patients whom lung are trapped.

Long-term survival of a young patient after multi-disciplinary treatment of initially inoperable stomach cancer with metastases to the liver and visceral lymph node

This paper reports on a 5-year survival of a 30-year-old male patient initially diagnosed with inoperable stomach cancer with metastases to the liver and the visceral lymph node. The systemic treatment regimen (8 cycles of DCF chemotherapy) resulted in an almost complete regression and enabled implementation of a radical resection of the stomach along with the spleen. Eight months into the treatment, the disease progressed producing several metastatic lesions to the liver. The patient received second-line palliative chemotherapy (4 cycles of EOX) which led to a significant reduction of the lesions. This enabled hepatic metastasectomy. The patient has remained in remission for 3 years.

Second-Line Palliative Chemotherapy in Advanced Gall Bladder Cancer, CAP-IRI: Safe and Effective Option.

Gall bladder cancer (GBC) has high prevalence in the Indo-Gangetic belt in India. While the first-line chemotherapy (CT1) has been established as gemcitabine-platinum doublet in advanced GBC, there is no standard recommendation or guidelines regarding feasibility of second-line therapy. We performed a retrospective analysis of all patients who received second-line of chemotherapy (CT2) at our institution from July 2012 to December 2014. Patient records were examined for efficacy and toxicity of administered CT2, along with response rates (RR) and survival. Potential prognostic factors were also evaluated. Eighty-seven patients received CT2 in the predefined period. Ninety-nine percent of patients had received a gemcitabine-based regimen as CT1 with a median progression-free survival (PFS) of 5months before CT2. 51.7% patients had undergone surgery prior with 5.7% patients having received radiotherapy previously. Prior to beginning CT2, PS was 0/1 in 67.8% patients, albumin was >4g% in 40.2% and CA 19.9 was raised in a majority (66.7%) patients, respectively. As per institution protocol, a majority of patients (89.6%) were administered CAP-IRI regimen. Overall RR and disease control rates(DCR) were 21.8 % and 41.3%, respectively. Median progression-free survival (PFS) and overall survival (OS) were 6 and 8months, with no significant differences between CAP-IRI and other regimens. Adverse effects were tolerable, with dose reduced upfront in 23% patients and 11.5% patients during subsequent cycles of CT. ECOG Performance Status (PS) of 0/1 was a significant prognostic variable for OS on multivariate analysis (p = 0.003). CAP-IRI is a well-tolerated second-line chemotherapeutic regimen in patients with advanced GBC. Careful selection of patients is required when administering second-line chemotherapy to advanced GBC patients, with particular emphasis on ECOG PS.