Catálogo de publicaciones - libros

Histopathologic examinations of resected specimens have revealed that the development of local recurrence after rectal surgery for cancer is related to the resection margin of the mesorectum. The incidence rate of local pelvic recurrence after standard “curative” surgery for rectal cancer varies widely. The treatment of local recurrence remains a challenge. Extensive resection (abdominal sacral resection with or without pelvic exenteration) gives the best chance of survival. For patients with unresectable recurrent rectal cancer, neither intravenous systemic chemotherapy nor intraarterial chemotherapy achieve desirable results in terms of pain control and tumor response. To improve clinical response, several methods of regional chemotherapy delivery have been suggested. One of these is regional pelvic perfusion. In our study, hypoxic pelvic perfusion has been proposed as palliative treatment in patients with unresectable locally recurrent rectal cancer who are nonresponders or who have disease progression after the standard modalities. The median survival time (12.2 mo) registered after one course of hypoxic pelvic perfusion is comparable to that obtained by irradiation or reirradiation in non-pretreated patients. Considering the vascular damage following radiotherapy, a different sequence in the multimodular treatment of unresectable recurrent rectal cancer could be more useful. Further studies are necessary to establish whether hypoxic pelvic perfusion improves the quality of life and survival of these patients if administered before radiotherapy with or without concomitant systemic chemotherapy. In conclusion, hypoxic pelvic perfusion is a good palliative treatment for patients with unresectable locally recurrent rectal cancer, but it should be considered as a link of a chain in a multimodular approach.

CT guidance allows for placement of a laser applicator into a pulmonary metastasis while the patient is under conscious sedation. The metastasis may thus be thermally destroyed. We describe how a laser applicator used in pulmonary lesions is designed; how complications from laser ablation compare to diagnostic biopsies; and how the technique may supplement traditional surgical therapy. It should be mentioned that following laser ablation, lesions enlarge, and it may take weeks or months before scar formation is reached. The technique is compared with other modalities and the necessity to combine it with local pharmaceutical approaches is discussed.

Treatment of primary brain tumors is complicated by many factors such as resistance to conventional treatments and the susceptibility of normal brain tissue to adverse effects of therapy combined with limited capacity for repair. Malignant gliomas (anaplastic astrocytoma and Glioblastoma multiforme), the most malignant brain tumors, have a poor prognosis because of their widely invasive nature, which makes a complete resection almost impossible. The current standard first-line therapy with surgery, radiotherapy, and subsequent chemotherapy fails to control tumor growth permanently or prevent relapses, and only a small increase in survival has been achieved over the last decades, despite advances in neuroimaging, neurosurgery, radiation therapy, and chemotherapy. Treatment of malignant gliomas has therefore been among the most challenging fields in oncology for more than 20 yr and investigators have developed new innovative therapies designed to augment local tumor control.

Hyperthermic intrapleural chemotherapy for malignant pleural disease aims to increase the exposure of malignant cells at the pleural surface to chemotherapeutic agents. Evidence is presented that indeed intrapleural perfusion can result in local exposure for cisplatin and doxorubicin of 60 to 100 times the systemic exposure. Combining chemotherapeutic perfusion of the pleural cavity with mild hyperthermia of 40°–42°C can probably further increase effective tumor cell kill. Effective penetration of the drugs is limited, however. This type of therapy can therefore only work in cases of microscopic residual disease, after complete surgical resection of all malignant pleural disease. A review is presented of studies using this approach in malignant pleural mesothelioma and in pleural involvement in non-small cell lung cancer. In neither disease is there any solid evidence to prove effectivness of hyperthermic pleural chemotherapy. Only in patients with pleural metastases of malignant tymoma has this approach resulted in some unexpected long-term survivors.

Management of locally advanced soft tissue sarcomas (STS) of the extremities that leads to an increase in preservation of functional limb continues to be a challenge. Isolated limb perfusion (ILP) with TNF-α and melphalan is a locoregional approach for advanced soft tissue sarcomas that has proved to be very effective to achieve this goal. The most prominent antineoplastic effect of TNF-α involves tumor vascularization, owing to early and selective alterations in tumor-associated endothelial cells, resulting in destruction of the tumor vessels. ILP may render a nonresectable tumor resectable and may reduce the local recurrence rate; in cases with widespread metastases, it can be used palliatively to avoid ablative surgery. ILP with TNF-α and melphalan has been shown to result in excellent response rates over 75% and to achieve long-term limb salvage rates in approx 80% of patients.

The treatment of melanoma in transit metastases can vary widely and is dependent on the size and number of lesions. When many, large lesions exist, isolated limb perfusion (ILP) can be used as an attractive treatment option with high response rates. We review here the various methods of treatment for melanoma in transit metastases, with a focus on ILP. Indications and results are discussed, and the extra value of tumour necrosis factor (TNF) is evaluated. ILP with melphalan results in complete response rates of 40 to 82% (54% in a large retrospective metaanalysis). The addition of TNF can improve these complete response rates (59–85%), and although no data from randomized controlled trials are available, TNF seems of particular value in large, bulky lesions or in patients with recurrent disease after previous ILP. TNF-based ILP has earned a permanent place in the treatment of patients with melanoma it transit metastases. In patients with a high tumor burden, TNF-based ILP is the most efficacious procedure to obtain local control and achieve limb salvage.

Prostate cancer and lung carcinoma are the most common cancers in the western world. Better screening methods especially the introduction of prostate specific antigen (PSA) screening in the beginning of the 1990s, have increased the early detection rate. In the United States only 30% of prostate tumors discovered were at an early stage before the introduction of PSA screening, compared with >60% nowadays. Early detection also increased the number of younger men among these patients. Patient demands have increased with respect to incontinence and impotence, especially among those young patients. Radical prostatectomy is still the gold standard for therapy of localized prostate cancer. Better operating techniques have decreased the side effects of this operation, but many patients still do not undergo this operation because they fear the side effects. Low dose rate (LDR) brachytherapy using permanent seeds originated in the United States and has had a renaissance in recent years. In 2004 alone, more than 50,000 patients were successfully treated using this technique. Ten-year data published as early as 1998 showed similar results compared with a multitude of radical prostatectomy studies and superior results to most of the published external beam studies, with significantly fewer side effects. Recently published 15-yr follow-up data support these findings. In Germany and Western Europe, more and more centers began with LDR brachytherapy. In contrast to the United States, where brachytherapy is mostly performed as an outpatient procedure, many European centers do only inpatient brachytherapy, with only a few centers performing outpatient procedures. Among them is the Ambulantes Operationszentrum im Ullsteinhaus in Berlin. The results from this center are very encouraging: few complications, high-quality treatment, and high patient acceptance.