Use Of Multimodal Therapy Research Articles

Thyroid Metastases from Renal Clear Cell Carcinoma Resected 9 Years Ago: A Fascinating Case Report and Review of Literature

Introduction: Kidney cancer is relatively rare when compered to other malignancies. It accounts for approximately 3% of adult malignancies. The renal clear cell carcinoma (RCCC) is the most common. In 70% of cases the disease is confined to the kidney and surgical approaches are generally curative. One third of cases is discovered in metastatic stage (30% of cases), specially bone and lung metastases; however, other rare metastases sites have also been described. Case report: We report a fascinating case of kidney cancer with thyroid metastases, discovered fortuitously during the surgical management of multinodular goitre; in a 54 years-old-woman with a history of nephrectomy 9 years ago for renal neoplasm. Conclusion: Thyroid metastases of kidney cancer are uncommon, it´s important for the surgeon and the oncologist to be able to recognize and differentiate thyroid metastases from primary tumours. The diagnosis can be suspected if the patient has a thyroid tumour and a past history of kidney cancer. These tumours, on the whole, tend to behave more aggressively and in most cases the use of multimodal therapy is recommended.

Inhibition of CDH17 gene expression via RNA interference reduces proliferation and apoptosis of human MKN28 gastric cancer cells.

Gastric cancer is the fourth most common type of cancer and the second cause of cancer-related mortalities worldwide despite the use of multimodal therapy. Cadherins are transmembrane glycoproteins that are involved in tumorigenesis. CDH17 has been found to be over-expressed in gastric cancer and its overexpression was associated with lymph node metastasis and tumor-node-metastasis stage of the patients, yet the exact role and molecular mechanism of CDH17 in gastric cancer have not been determined. Using a lentiviral system as a delivery mediator of RNA interference, we found that inhibition of CDH17 can lead to reduce proliferation and increase apoptosis of gastric cancer cell line MKN28 in vitro and significantly diminish their tumorigenicity in vivo. Our results of the present study suggest that CDH17 may be a promising candidate for the therapeutic targeting of gastric cancer.

Prevention and management of anterior resection syndrome

Because of the improvement of surgical technique and the widely use of multimodality therapy, more patients with rectal cancer undergo sphincter-preserving surgery. However, it has been reported that up to 90% of such patients will suffer from bowel dysfunction, ranging from increased bowel frequency to faecal incontinence or evacuatory dysfunction. This wide spectrum of symptoms after resection of the rectum has been termed anterior resection syndrome (ARS). This disordered bowel function has a substantial negative effect on quality of life, however, the causal mechanisms have not been clarified. The present review discusses the clinical manifestation, underlying mechanisms, as well as prevention and treatment strategies.

Comparing Gabapentin and Celecoxib in Pain Management and Complications After Laminectomy: A Randomized Double-Blind Clinical Trial.

BackgroundComplications and postoperative pain are major care problems that can affect the quality of health care plan.ObjectivesAccording to the use of multimodal therapy the current study aimed to compare the efficacy of gabapentin and celecoxib in pain management and complications after laminectomy at Ilam University of Medical Sciences, Ilam, Iran, in 2015.Patients and MethodsIn this randomized double-blind clinical trial, 114 patients scheduled for elective laminectomy with simple random sampling design received gabapentin (n = 38, 900 mg/day), celecoxib (n = 38, 600 mg/day) and placebo (n = 38, capsule contain starch). Visual analog scale (VAS) was used to determine the intensity of pain. Complications after surgery, anxiety scores before surgery and patient’s satisfaction 24 hours after the surgery were recorded.ResultsThe mean pain intensity in the gabapentin group was lower compared to those of the placebo and celecoxib groups respectively at different time durations (P < 0.001). The means of morphine consumption were 11.9 mg, 22.8 mg and 30.1 mg in the gabapentin, celecoxib and placebo groups, respectively (P < 0.001). The prevalence of shivering, nausea, vomiting and pruritus were 10.5%, 12.8%, 10.3% and 18.4% in the gabapentin group vs 31.5%, 29.8%, 32.4% and 28.9% in the celecoxib group and 42.1%, 44.7%, 39.5% and 44.7% in the placebo group (P < 0.001). The mean anxiety score in the gabapentin group was 2.4 vs those of the celecoxib group 3 and placebo group 3.6 (P < 0.001). The frequencies of drowsiness were 42.1%, 13.2% and 5.3% in the gabapentin, celecoxib and placebo groups, respectively (P < 0.001). In the gabapentin group, patient satisfaction was significantly higher compared to those of the placebo and celecoxib groups (P < 0.05).ConclusionsAccording to the effect of gabapentin on pain management, complications after laminectomy and increased patients satisfaction, it can be regarded as an alter native in multimodal analgesia.

Improved Nutrition in Adolescents and Young Adults after childhood cancer: INAYA—A pilot study.

173 Background: By the use of multimodal therapies the chance of cure and survival improves and thus the risk for long-term side effects are increasing in „Adolescents and Young Adult“ cancer survivors (AYAs) . Compared to the general population AYAs have a 5 to 15-fold increased risk of cardiovascular diseases. Therefore, the improvement of modifiable lifestyle risk factors is of importance. Besides general information supplied during survivorship care nutrition habits in AYAs remain bad. Methods: The INAYA trial enrolled AYAs between 18-39 years to receive an intensified individual nutrition counseling based on a 3-day dietary records at 4 defined timepoints. At week 0 and 12 AYAs got personal counseling during follow-up care and consultation hours and at week 2 and 6 by telephone. Primary endpoint was change in nutritional intake measured by the Healthy Eating Index of the European Prospective Investigation into Cancer and Nutrition (HEI-EPIC). Secondary endpoints were (selection): quality of life (QoL), change in weight and waist-hip ratio. Results: 23 AYAs (11 female, 12 male, 21.9 ± 4.3 years of age, BMI: 21.6 ± 1.7 kg/m²) after treatment for childhood malignancies (12x hodgkin lymphoma, 6x leukaemia, 2x sarcoma, 2x carcinoma, 1x blastoma) were included. At baseline 14 patients (pts) were of normal weight, 4 pts overweight and 5 pts underweight (WHO criteria). 56.5% (n = 13) reported gastrointestinal symptoms (e.g. flatulence, change in stool consistency, stomach pain). According to HEI-EPIC a good, moderate and bad nutritional intake was seen in 4.3%, 73.9% and 21.7% of the pts. A high salt intake was seen in 6 pts (26%). Dietary habits improved after nutrition counseling at week 0, 2 and 6. 43.7% (n = 10) took more time to eat, 47.8% (n = 11) increased their fluid intake to ≥ 1.5 l/d and 21.7% (n = 5) changed their weight positively. Up to now 8 pts completed the study. Median HEI-EPIC score improved from 46 points (baseline) to 66 points (week 12). Final results are expected for November 2015. Conclusions: Intensified nutrition counselling improves dietary intake and nutrition status in AYAs.

2016

Postsurgical pain, like that associated with major upper extremity surgery, can be significant and usually require the use of opioid analgesics. However, opioids are associated with significant adverse effects, including respiratory depression, which often drive the use of multimodal therapy with nonopioid analgesics, including local and regional analgesia techniques. However, use of older local anesthetics provides a limited duration of analgesia. An innovative formulation of liposomal bupivacaine (Exparel), which is approved for surgical site infiltration, can provide a longer duration of analgesia. Because optimal pain relief relies on the success of the surgical site infiltration technique, a group convened to address best practices for periarticular injection techniques for shoulder surgery. This article reviews the neuroanatomy of the shoulder, recommends optimal solutions (i.e., analgesic cocktails) and volume for injection, and provides a detailed description of the infiltration technique to develop the best approach to periarticular injection for major shoulder surgery.

Trends in Receipt and Timing of Multimodality Therapy in Early-Stage Pancreatic Cancer

IntroductionPancreatic cancer is considered a systemic disease at presentation. Therefore, multimodality therapy with surgical resection and chemotherapy is the standard of care for locoregional disease. We described treatment patterns and time trends with regard to age and treatment center in the receipt of multimodality therapy. MethodsWe used the National Cancer Data Base to identify patients ≥18 years old with stage I and II pancreatic adenocarcinoma. Treatment was defined as no treatment, resection only, chemotherapy only, or multimodality therapy, which consisted of both chemotherapy (neoadjuvant or adjuvant) and resection. Trends in the receipt and type of treatment were compared. ResultsOf 39,441 patients, 22.8 % of patients received no treatment, 18.5 % received chemotherapy only, 23.0 % underwent surgical resection alone, and 35.8 % of patients received multimodality therapy. Receipt of multimodality therapy increased from 31.3 % in 2004 to 37.9 % in 2011 (p < 0.0001). Patients >55 years were less likely to receive multimodality therapy (56–64 years: OR 0.83, 95 % CI 0.78–0.89; 65–75: OR 0.60, 95 % CI 0.55–0.65; ≥76: OR 0.17, 95 % CI 0.16–0.19 compared to patients 18–55). Compared to community hospitals, patients treated at an NCI-designated center were more likely to receive multimodality therapy (OR 1.62, 95 % CI 1.46–1.81) and, if they received multimodality therapy, delivery of chemotherapy in the neoadjuvant compared to adjuvant setting (OR 2.82, 95 % CI 2.00–3.98). ConclusionDespite increased use of multimodality therapy, it remains underutilized in all patients and especially in older patients. Receipt of multimodality therapy and neoadjuvant therapy is highly dependent on treatment at NCI-designated cancer centers.

Multimodality Treatment of T4 Gastric Cancer in the United States: Utilization Trends and Impact on Survival.

National guidelines advocate use of multimodality therapy (MMT) for treatment of T4 gastric cancer (T4GC). Prior studies demonstrate poor compliance with these guidelines. We sought to assess treatment trends and association between different treatment approaches and overall survival (OS) in a large cohort of U.S. Patients diagnosed with clinical T4 gastric adenocarcinoma were selected from the National Cancer Data Base (1998-2011). Temporal trends, risk factors associated with failure to receive treatment, and effect of treatments on OS were assessed. Of 4369 patients with T4GC, only 15 % (n = 652) received MMT. Treatment with MMT increased over time, and was utilized in 25 % of patients after 2006. Older age, African American race, nonprivate insurance, proximal tumor location, and clinical node-negative disease were associated with failure to receive surgery; older age, female sex, poorly differentiated tumor grade, clinical node-negative disease, and prolonged postoperative length of stay were associated with failure to complete MMT in patients who underwent surgical resection. Median OS was longest in patients receiving MMT (19.2 months), and was similarly poor in patients undergoing surgical resection (9.0 months) or nonsurgical therapy (8.3 months; p < 0.001). Median OS was longer in patients receiving neoadjuvant therapy compared to patients receiving adjuvant therapy (27.8 vs. 16.6 months; p = 0.004). Treatment with neoadjuvant MMT is increasing and is associated with prolonged survival. Surgery alone and chemotherapy with or without radiotherapy without resection are associated with similarly poor outcomes. Appropriate treatment sequencing may facilitate delivery of MMT and improve outcomes in patients with T4GC.

Mutational analysis of matched initial and recurrent TP53 WT primary GBM.

2043 Background: Glioblastoma (GBM) present as a heterogeneous disease with poor prognosis despite the use of multimodal therapy. Tumours at diagnosis are distinct from their recurrences, the latte...

Incidence of second primary cancers with pediatric high grade glioma: Single institution experience.

e21023 Background: Children with high grade gliomas (HGG) continue to have a poor prognosis despite the use of multimodality therapy. HGG may rarely occur as part of cancer predisposition syndromes (CPS) and to be associated with other primary second cancers (PSC). We aim to evaluate the incidence of PSC with HGG at King Hussein Cancer Center, Jordan Methods: We retrospectively reviewed neurooncology database between 2003 -2013. We included patients > 3 and < 18 years and in whom we could review and confirm HGG diagnosis. We described their clinical characteristics, survival and incidence of PSC Results: 42 patients were identified (29 males, 24 Jordanians). Median age was 11.3 years (3.1-17.9). Main presenting symptoms were increased intracranial pressure in 22 (52%), focal deficits in 13 and convulsions in 10. Fourteen (67%) patients with available clinical data had cafe au lait spots (CAL). Family history of cancer was reported in 13/31 and consanguinity in 10/30. Twelve patients (29%) had near total t...

Angiosarcoma of the scalp and face: the Mayo Clinic experience.

The etiology and optimal treatment are unknown for angiosarcoma, an aggressive malignant tumor that affects vascular endothelial cells and can be mistaken for benign lesions such as hemangioma. To determine the treatment outcomes of patients with angiosarcoma of the face or scalp treated with a combination of surgery, radiation therapy, and/or chemotherapy. Retrospective study of 55 patients with angiosarcoma of the face or scalp treated between January 1, 1973, and December 31, 2012, at a tertiary-care academic medical institution. Surgery, radiation therapy, and/or chemotherapy. Locoregional control (LRC), recurrence-free survival (RFS), and overall survival (OS). Fifty-five patients had angiosarcoma localized to the face or scalp. Forty of these patients (73%) received a combination of surgery, radiation therapy, and/or chemotherapy. Eight patients (15%) were treated with surgery alone, 1 (2%) with radiation alone, 5 (9%) with chemotherapy alone, and 1 (2%) with observation alone. Median (range) follow-up for surviving patients was 25.2 (4.7-227.1) months. Five-year LRC, RFS, and OS (95% CI) were 18% (7%-32%), 16% (6%-31%), and 38% (21%-54%), respectively. Of 36 patients with failed treatment, 34 had failure in a local and/or regional site. On univariate analysis, the use of multimodality therapy (vs no multimodality therapy) was associated with higher 5-year LRC (95% CI) (20% [3%-37%] vs 11% [0%-29%]; P = .04), higher RFS (19% [2%-36%] vs 10% [0%-27%]; P = .02), and higher OS (46% [26%-66%] vs 16% [0%-43%]; P = .04). Age 70 years or older (vs <70 years) was associated with lower 5-year LRC (95% CI) (5% [0%-14%] vs 48% [23%-74%]; P = .02) and lower RFS (5% [0%-13%] vs 49% [24%-75%]; P = .04). Radiation therapy (vs no radiation therapy) was associated with higher 5-year LRC (95% CI) (20% [3%-36%] vs 12% [0%-32%]; P = .02) and higher RFS (19% [2%-35%] vs 12% [0%-31%]; P = .004). On multivariable analysis, age younger than 70 years (vs ≥70 years) was associated with improved 5-year LRC (95% CI) (48% [23%-74%] vs 5% [0%-14%]; P = .03) and RFS (49% [24%-75%] vs 49% [24%-75%]; P = .04). Multimodality therapy for angiosarcoma is associated with improved LRC, RFS, and OS. Younger patients with resectable disease undergoing multimodality therapy for angiosarcoma had the best clinical outcomes.

Multimodality management of borderline resectable pancreatic neuroendocrine tumors: Sentinel report of a single-institutional experience.

418 Background: Pancreatic neuroendocrine tumors (PNET) constitute about 3% of pancreatic neoplasms. In borderline resectable disease, there is a lack of data to support an optimal neoadjuvant approach for curative outcomes. We describe our institutional experience with a multimodality approach. Methods: We identified all patients with borderline resectable PNET, using NCCN criteria for adenocarcinoma of the pancreas, who received neoadjuvant therapy at our institution between 2000 and 2013. The reason for borderline status was noted. Neoadjuvant regimen, radiographic response, pathologic response, surgical margins, nodal harvest, number of positive nodes, and recurrence were all documented. Results: A total of 112 patients had undergone pancreatic resections for neuroendocrine tumors during the study period. Six patients had borderline resectable disease. The mean age was 55 years (24-70). They all received at least 1 cycle of Temodar and Xeloda. Three of the six patients also received concurrent 5-FU and radiation. There was radiographic evidence of treatment response in all patients. Five of six patients (83 %) had negative margin (R0) resection. Low volume miliary metastatic disease in the liver was detected in 1 patient at the time of surgery. The median number of lymph nodes harvested was 12. Half of the patients had node positive disease. On pathologic review, 4 patients had histologic evidence of a moderate response. All patients are alive and 5/6 are free of disease. Range of follow up is 3.0-4.32 years. The patient with metastatic disease has had no progression and is the only one who is currently receiving any form of treatment. Conclusions: Neoadjuvant Temodar and Xeloda ± radiation with 5-FU sensitization can lead to R0 resection with durable response in patients with borderline resectable PNET. To our knowledge, this is the first report of the use of multimodality therapy (neoadjuvant chemotherapy ± chemoradiation and surgery) in the treatment of borderline resectable PNET.

Successful use of metronomic vinblastine and fluorothymidine pet imaging for the management of intramedullary spinal cord anaplastic oligoastrocytoma in a child.

Children with high-grade glioma still have a poor prognosis despite the use of multimodal therapy including surgery, radiotherapy, and chemotherapy. New therapeutic strategies and methods evaluating such therapies are needed. Here we describe a child with anaplastic oligodendroglioma of the spinal cord who was unable to tolerate standard chemoradiotherapy and who had still-vital residual tumour during therapy. A good response was obtained with low-dose metronomic treatment containing vinblastine. The treatment was guided according to gradual response assessed using various positron-emission tomography tracers. Metronomic treatment guided by positron-emission tomography could be a reasonable option in some high-risk pediatric tumours.

Platinum sensitivity and CD133 expression as risk and prognostic predictors of central nervous system metastases in patients with epithelial ovarian cancer.

BackgroundTo characterize prognostic and risk factors of central nervous system (CNS) metastases in patients with epithelial ovarian cancer (EOC).MethodsA retrospective analysis of Xijing Hospital electronic medical records was conducted to identify patients with pathologically confirmed EOC and CNS metastases. In addition to patient demographics, tumor pathology, treatment regimens, and clinical outcomes, we compared putative cancer stem cell marker CD133 expression patterns in primary and metastatic lesions as well as in recurrent EOC with and without CNS metastases.ResultsAmong 1366 patients with EOC, metastatic CNS lesions were present in 29 (2.1%) cases. CD133 expression in primary tumor was the only independent risk factor for CNS metastases; whilst the extent of surgical resection of primary EOC and platinum resistance were two independent factors significantly associated with time to CNS metastases. Absence of CD133 expression in primary tumors was significantly associated with high platinum sensitivity in both patient groups with and without CNS metastases. Platinum resistance and CD133 cluster formation in CNS metastases were associated with decreased survival, while multimodal therapy including stereotactic radiosurgery (SRS) for CNS metastases was associated with increased survival following the diagnosis of CNS metastases.ConclusionsThese data suggest that there exist a positive association between CD133 expression in primary EOC, platinum resistance and the increased risk of CNS metastases, as well as a less favorable prognosis of EOC. The absence of CD133 clusters and use of multimodal therapy including SRS could improve the outcome of metastatic lesions. Further investigation is warranted to elucidate the true nature of the association between platinum sensitivity, CD133 expression, and the risk and prognosis of CNS metastases from EOC.

Multi-Modal Pain Therapy of Fibromyalgia Syndrome with Integration of Systemic Whole-Body Hyperthermia – Effects on Pain Intensity and Mental State: A Non-Randomised Controlled Study

Objectives: This controlled study evaluates a multi-modal pain therapy for treating severe progressions of fibromyalgia [FMS] syndrome. The aim is to establish whether the use of multi-modal therapy with inclusion of whole-body hyperthermia represents a useful therapeutic addition to inpatient therapy of FMS syndrome at a high level of chronification.Methods: The study involved 130 patients who fulfilled the criteria of the American College of Rheumatology [ACR] for FMS and whose disease showed severe progression. One group of patients [HTG] received whole-body hyperthermia, while the control group [CG] did not. The main parameters of the study were pain intensity and the mental state of the patients. Further study parameters were the diagnoses additional to FMS syndrome and the therapy density of the treatment provided in the two groups.Results: The integration of whole-body hyperthermia into the multi-modal pain therapy showed superior pain reduction [p = 0.023] and an improvement in the mental state of the patients [p = 0.055]. In addition to the primary disease, the patients presented with an average of 6.7 accompanying diseases, primarily from major diagnostic categories 8 [diseases and disturbances of the musculoskeletal system and connective tissues], 19 [mental diseases and disturbances] and 10 [endocrine, nutritional and metabolic diseases]. Analysis of the therapy density of the inpatient multi-modal pain therapy revealed a close-meshed and high-frequency therapy.Conclusions: Multi-modal pain therapy was also found to be a highly effective therapy option in the case of severely progressive FMS syndrome. Extension of the multi-modal therapy setting to include whole-body hyperthermia can be considered as a useful and effective complement for pain relief and stabilisation of the mental state.

Implications of inadequate lymph node staging in resectable gastric cancer: A contemporary analysis using the National Cancer Data Base

National guidelines recommend examination of ≥ 15 lymph nodes for adequate staging of resectable gastric adenocarcinoma (GA). The relevance of these guidelines, which were established before the increasing use of multimodality therapy, and the impact of inadequate lymph node staging (LNS) in a contemporary cohort have not been extensively explored. Stage I-III GA patients who underwent gastrectomy from 1998 to 2011 were identified using the National Cancer Data Base. Trends in LNS adequacy, predictors of inadequate LNS (< 15 LN examined) and the relationship between LNS and overall survival (OS) were analyzed. In 22,409 patients, compliance with LNS guidelines was poor (inadequate LNS in 61.2% of cases, median LN harvested in 11.0%). Subtotal/partial gastrectomy was the strongest predictor of inadequate LNS (OR = 2.01, P < .001). Survival analyses included 9139 patients with minimum 5 years follow-up; median, 1-year, and 5-year survival was 35.6 months, 75.5%, and 39.7%, respectively. LN positivity (HR = 1.90) and age > 76 years (HR = 1.73) were the strongest predictors of worse OS (both P < .001). Inadequate LNS was independently associated with worse OS (HR = 1.33, P < .001). Median OS after inadequate compared to adequate LNS was significantly worse (33.3 months versus 42.0 months, P < .001), regardless of AJCC clinical stage subgroup or tumor T classification (both P < .001). Adequate LNS is achieved in a minority of patients. Inadequate LNS was independently associated with worse OS. Examination of ≥ 15 LN is a reproducible prognosticator of gastric cancer outcomes in the United States and should continue to serve as a benchmark for quality of care.

Trajectory of care and use of multimodality therapy in older patients with pancreatic adenocarcinoma

Multimodality therapy with chemotherapy and operative resection is recommended for patients with locoregional pancreatic cancer but is not received by many patients. To evaluate patterns in the use and timing of chemotherapy and resection and factors associated with receipt of multimodality therapy in older patients with locoregional pancreatic cancer. We used Surveillance, Epidemiology, and End Results-linked Medicare data (1992-2007) to identify patients with locoregional pancreatic adenocarcinoma. Multimodality therapy was defined as receipt of both chemotherapy and pancreatic resection. Logistic regression was used to determine factors independently associated with receipt of multimodality therapy. Log-rank tests were used to identify differences in survival for patients stratified by type and timing of treatment. We identified 10,505 patients with pancreatic adenocarcinoma. 5,358 patients (51.0%) received either chemotherapy or surgery, with 1,166 patients (11.1%) receiving both modalities. Resection alone was performed in 1,138 patients (10.8%), and chemotherapy alone was given to 3,054 (29.1%) patients. In patients undergoing resection as the initial treatment modality, 49.4% never received chemotherapy; 97.4% of patients who underwent chemotherapy as the initial treatment modality never underwent resection. The use of multimodality therapy increased from 7.4% of patients in 1992-1995 to 13.8% of patients in 2004-2007 (P < .0001). The 2-year survival was 41.0% for patients receiving multimodality therapy, 25.1% with resection alone, and 12.5% with chemotherapy alone (P < .0001). Of the patients receiving multimodality therapy, chemotherapy was delivered in the adjuvant setting in 93.1% and in the neoadjuvant setting in 6.9%, with similar 2-year survival with either approach (neoadjuvant vs adjuvant, 46.9% vs 40.6%; P = .16). Year of diagnosis, white race, less comorbidity, and no vascular invasion were independently associated with receipt of multimodality therapy. Only half of older patients with locoregional pancreatic cancer receive any treatment, and fewer than one quarter of treated patients receive multimodality therapy. Nearly all patients receiving chemotherapy as the initial treatment modality did not undergo resection, whereas half of those undergoing resection first received chemotherapy. When multimodality therapy is used, the vast majority of patients had chemotherapy in the adjuvant setting with a similar survival, regardless of approach.

Trends of multimodal therapy in high-stage penile cancer.

370 Background: Penile cancer (PC) is associated with high mortality and treatment failure in higher stage disease. While no prospective data exists, small anecdotal reports advocate the use of perioperative chemotherapy and/or radiotherapy for advanced disease. The 2013 National Comprehensive Cancer Network (NCCN) guidelines advocate the use of multimodal therapy for advanced disease. This study aimed to examine the trend in the use of perioperative chemotherapy or radiotherapy for advanced stage PC in the U.S. from 2000 – 2011. Methods: The National Cancer Database (NCDB) Datalinks Portal was queried. Diagnosis by year, first course treatment by stage, in all hospitals from 2000 – 2011 was obtained. Percentages of men treated with surgery alone, surgery with radiation, and surgery with chemotherapy in stages III and IV by year were determined to assess trends. Results: From 2000 – 2011, there were 1,028 and 440 men diagnosed with stage III and IV PC, respectively, who were recorded as having either surgery alone, surgery with radiation (+XRT), or surgery with chemotherapy (+Chemo). Addition of radiation therapy was variable, but low. Addition of chemotherapy has gradually increased, most dramatically in stage III PC. Conclusions: Consistent with the 2013 NCCN guidelines on penile cancer, the use of multimodal therapy for higher stage PC has increased, though modestly. Surgery with chemotherapy is the most common multimodal therapy. Further studies are needed to determine if this corresponds to a change in PC mortality. [Table: see text]

Trajectory of Care and Use of Multimodality Therapy in Patients with Locoregional Pancreatic Adenocarcinoma

Trajectory of Care and Use of Multimodality Therapy in Patients with Locoregional Pancreatic Adenocarcinoma

Multimodality treatment of potentially curative gastric cancer: geographical variations and future prospects.

After much controversy, multimodality therapy is now accepted worldwide as the gold standard for treatment of resectable bulky localized gastric cancer. There is significant regional variation in the style of multimodality treatment with adjuvant chemoradiation the North American standard, neoadjuvant chemotherapy preferred in Europe and Australasia, whilst adjuvant chemotherapy is preferred in Asia. With further standardization of surgery and D1+/D2 resections increasingly accepted world wide, and in particular in the West, as the surgical standard of care for potentially curable disease, it is timely to reassess the multimodality regimes being used. The challenge in the use of multimodality therapy is how current outcomes can be standardized and improved further. Recent studies indicate that mere intensification of the regime in time, dosage or addition of further agents does not improve localized gastric cancer outcomes. More novel strategies including early commencement of adjuvant therapies, intra-peritoneal chemotherapy or assessing neoadjuvant response with positron emission tomography scanning may give improvements in outcomes. The introduction of targeted therapies means that the adjuvant use of biological agents needs to be explored. By proper assessment of the patient's co-morbidities, full tumour staging, and a better understanding of the tumour's molecular pathology, multimodality therapy for gastric adenocarcinoma may be individualized to optimize the likelihood of cure.