memo - Magazine of European Medical Oncology

Lordick, F.

2012 memo - Magazine of European Medical Oncology

doi: 10.1007/s12254-012-0326-3

2012 memo - Magazine of European Medical Oncology

doi: 10.1007/s12254-012-0334-3

Gunsilius, E.

2012 memo - Magazine of European Medical Oncology

doi: 10.1007/s12254-012-0337-0

Dörler, J.; Pölzl, G.

2012 memo - Magazine of European Medical Oncology

doi: 10.1007/s12254-012-0340-5

Cardiac involvement can be found in all types of amyloidosis, but is most frequent in AL amyloidosis. Severity of cardiac infiltration is by far the most relevant prognostic determinant. Once the heart is affected, amyloidosis carries a poor prognosis. Diagnosis is based on non-invasive testing such as ECG, echocardiography and cardiac MRI (CMR). However, endomyocardial biopsy is needed to unequivocally confirm cardiac infiltration and for immunohistochemical differentiation. Therapy primarily aims to reduce amyloid precursor proteins and treat end-organ failure. Specific cardiologic therapy is largely restricted to diuretics, anticoagulation and pacemaker implantation. In rare cases urgent heart transplantation followed by high-dose chemotherapy and stem cell transplantation can be considered.

Heininger, D.

2012 memo - Magazine of European Medical Oncology

doi: 10.1007/s12254-012-0341-4

The term "amyloidosis" covers a group of conditions characterised by extracellular protein deposits in the form of insoluble fibrils with a beta-pleated sheet structure. Systemic amyloidoses very often involve the kidney, as the primary AL (Ig light chains), the secondary AA (amyloid A), but also some hereditary forms of amyloidosis. The main renal symptom of amyloidosis is proteinuria. In addition to histological work-up using lightmicroscopy, immunohistochemistry and electronmicroscopy, diagnosis often calls for amyloid classification by means of DNA sequencing or laser microdissection with mass spectrometry. The therapeutic approach depends on the underlying primary disease but especially in AL amyloidosis new chemotherapeutic options and interesting data from bone marrow as well as solid organ transplantation have recently become available.

Graziadei, I.

2012 memo - Magazine of European Medical Oncology

doi: 10.1007/s12254-012-0344-1

There has been an enormous progress in the understanding of the pathogenesis, classification, clinical feature, diagnosis and treatment of amyloidosis over the past decades. Irrespective of the type of amyloidosis the amyloid protein can deposit in almost all parts of the gastrointestinal tract and liver resulting in various symptoms such as abdominal pain, dysphagia, dysmotility disorders, diarrhoea, gastrointestinal bleeding, hepato(spleno)megaly and portal hypertension with its associated complications mimicking the clinical picture of decompensated liver cirrhosis. Most gastrointestinal complications are treated symptomatically; a causal therapy is only reserved for various subtypes of amyloidosis. Liver transplantation is a therapeutic option for patients with familial amyloidotic polyneuropathy providing excellent long-term results.

Kimmich, C.; Hegenbart, U.; Goldschmidt, H.; Ho, A. D.; Schönland, S.

2012 memo - Magazine of European Medical Oncology

doi: 10.1007/s12254-012-0336-1

Systemic light-chain amyloidosis (AL amyloidosis) is a rare protein folding disorder in which monoclonal light chains are deposited as insoluble fibrillar aggregates. The most common cause of the disease is a monoclonal plasma cell disorder. Currently, the only clinically relevant treatment option is chemotherapy, targeting the underlying neoplastic cells. Patients are often in a poor general state of health with organ functions being impaired by amyloid deposits. In recent years, several new treatment protocols have been introduced, which give clinicians a variety of options to adapt treatment to the patients' needs. For this reason a thorough assessment must be performed so that each patient receives the best individual treatment option.

Müldür, E.; Weißmann, A.; Leitgeb, C.; Zojer, N.; Schreder, M.; Heintel, D.; Ludwig, H.

2012 memo - Magazine of European Medical Oncology

doi: 10.1007/s12254-012-0331-6

We present the case of a 72-year-old woman diagnosed with multiple myeloma (MM) in 1992 and treated with lenalidomide plus dexamethasone (LD) as third-line therapy. The patient achieved a complete remission (CR) after 6 cycles of LD treatment, was treated with LD for almost 4 years, and has now been in CR for 5 years. This case illustrates the potential of lenalidomide for continuous treatment in MM, with side effects controllable through tailored patient management including step-wise dose adaptations.

Willenbacher, E.; Willenbacher, W.; Gunsilius, E.

2012 memo - Magazine of European Medical Oncology

doi: 10.1007/s12254-012-0345-0

In multiple myeloma cells, particular genomic alterations, such as del17p, are considered to be associated with higher-risk disease. However, in recent years, the introduction of thalidomide, bortezomib and lenalidomide has substantially enriched the therapeutic armamentarium for both newly diagnosed and relapsed multiple myeloma patients with poor prognosis. We describe the case of such a patient (female, 60 years of age), who refused autologous stem cell transplantation and became refractory to an induction therapy with bortezomib. Subsequently, she did not tolerate a regimen containing thalidomide and therefore was started on maintenance therapy with lenalidomide. After 4 years of treatment, the patient still is in partial remission. Our case demonstrates the long-term efficacy and good tolerability of lenalidomide monotherapy in a pre-treated high-risk multiple myeloma patient. An individually adjusted dose of lenalidomide may be a good option for patients with refractory disease who are unable to tolerate or refuse to undergo autologous stem cell transplantation.

Weissinger, F.; Heinz, W. J.

2012 memo - Magazine of European Medical Oncology

doi: 10.1007/s12254-012-0335-2

Febrile Neutropenia is a relevant factor for mortality after chemotherapy. Dependent upon factors like duration of neutropenia (≥7 d means high-risk situation), patient- and disease specific criteria e.g. defined in the MASCC score (Multinational Association of Supportive Care in Cancer) the individual risk for the patient for the need of being hospitalized can be estimated. Antimicrobial therapy has to be started immediately, to avoid high mortality. Empiric or calculated antiinfective therapy includes broadspectrum-lactam antibiotics in first-line. After 72 to 96 h of treatment, when the patients are still febrile and clinically not improving, an empiric switch of the antibiotic treatment can be considered, e.g. closing the gaps in the gram-positive spectrum. In this situation high risk patients also should receive an antifungal agent with activity against aspergillus spp. Strategies to prevent infection in neutropenia are antiinfective prophylaxis or the use of G-CSF (granulocyte-colony stimulating factor). Antibiotic prophylaxis might help to prevent infections and to improve outcome esp. for high risk patients. Antifungal prophylaxis including Aspergillus species is recommended in the situation of induction therapy for acute myelogenic leukemia. Patients, expecting a phase of prolonged neutropenia with a history of mold infection should receive a secondary antifungal prophylaxis.

Rades, D.; Schild, S. E.

2012 memo - Magazine of European Medical Oncology

doi: 10.1007/s12254-012-0330-7

The effect of radiotherapy depends on optimal tumour oxygenation, as tumour hypoxia impairs the production of radiation-induced cytotoxic free radicals resulting in less tumour cell kill. The range of haemoglobin levels optimal for tumour oxygenation is 12–14 g/dl in women and 13–15 g/dl in men. It appears reasonable to elevate the haemoglobin level in anaemic cancer patients into this optimal range. This may be achieved with red blood cell transfusions (RBCT) or erythropoiesis stimulating agents (ESAs). However, RBCT have had negligible or even negative effect on patient outcome, possibly because RBCT induce immunosuppression or result in haemoglobin levels too high for optimal tumour oxygenation. Several randomized trials have demonstrated that patients irradiated for head-and-neck cancer had worse outcomes with ESAs than the control group. However, in the majority of these trials, over-treatment with ESAs resulted in haemoglobin levels above the optimal range. Tumour oxygenation is impaired by inappropriately high haemoglobin levels due to increased blood viscosity and decreased tumour cell perfusion. This concept is supported by the findings of prospective studies in cervix cancer and esophageal cancer patients. In these studies the ESA administration was withheld at a haemoglobin level of 14 g/dl resulting in a positive effect of ESAs on treatment outcome. In summary, the effect of RBCT and particularly of ESAs during radiotherapy remains unclear. Further randomized trials are required. Until such trials are available, one should follow the ASCO and ESMO guidelines that are very conservative regarding the administration of ESAs during radiotherapy and chemoradiation.

Becker-Schiebe, M.; Lordick, F.; Hoffmann, W.

2012 memo - Magazine of European Medical Oncology

doi: 10.1007/s12254-012-0325-4

During radiotherapy 80% to 90% of all patients will develop some degree of inflammation symptoms, such as erythema, dry or wet desquamation, skin folds, or mucositis depending on radiation-and patient-related factors and the extent of irradiated skin or mucosal areas. Up to now radiation induced local reactions represent still an important toxicity factor. Cutaneous and mucosal side effects may reduce the patient's compliance and can be limiting factors to follow radiotherapy protocols. Therefore, there is a high need for effective prophylactic and therapeutic treatments. Basically, guidelines recommend the avoidance of mechanical, chemical and thermal irritants, especially the exposure to high temperatures. To delay onset of radiodermatitis various preventive topicals may be applied like aqueous cream formula with or without antioxidative agents. In general, the treatment of radiodermatitis primarily should maintain moisture and skin permeability and consists of hydrophilic creams, antioxidative and anti-inflammatory topicals. Hydrocolloid dressings may reduce and improve wound healing in grade 2 and 3 reactions. Supportive therapy of radiation-induced mucositis includes the maintenance of oral care protocols and adequate nutrition during the course of treatment. A sufficient oral health status is one of the most important factors for prevention of severe oral complications. The MASCC guidelines recommend furthermore the use of non-medicated rinses with saline or sodium bicarbonate 4 to 6 times daily. Further approaches suggest the use of local anaesthetics and systemic analgesics for severe mucositis. Besides local preventive agents and supportive care protocols, modern radiation treatment techniques remain the most promising intervention in reducing the degree of skin reactions.

Stange, A.

2012 memo - Magazine of European Medical Oncology

doi: 10.1007/s12254-012-0338-z

Malignant ascites is a common problem in patients with advanced malignancies and peritoneal spread of tumour. Treatment strategies include paracentesis, diuretics and peritoneovenous shunts; however, there are no established evidence-based guidelines for optimal therapy. This review is intended to add clarity to the current procedures for the management of malignant ascites, and furthermore discusses new promising approaches.

Lorenzen, S.

2012 memo - Magazine of European Medical Oncology

doi: 10.1007/s12254-012-0329-0

In recent years, new drugs have increased efficacy in the prevention and control of chemotherapy-induced nausea and vomiting (CINV), however, vomiting, and especially nausea continue to be two of the most worrisome adverse effects of antineoplastic treatment. Antiemetic agents that have been identified to significantly improve the prophylaxis and treatment of CINV include the 5-HT3-receptor antagonists (RA), corticosteroids, neurokinin 1(NK1) receptor antagonists, dopamine receptor antagonists, benzodiazepines, neuroleptics and cannabinoids. However, there are still a significant number of patients experiencing CINV, either because of non-adherence to current treatment guidelines or due to the fact that antiemetic prophylaxis for new drugs, targeted therapies and prolonged oral therapy is not yet established appropriately. Due to the emergence of new findings and new antiemetic agents, the MASCC/ESMO and the ASCO updated their treatment guidelines for the prevention of CINV. The combination of anthracyclines and cyclophosphamide (AC) is classified as highly emetogenic and a triple therapy including a 5-HT3-RA, dexamethasone and an NK1-RA is recommended. While acute CINV can be sufficiently controlled with the combination of 5-HT3-RA plus dexamethasone, delayed CINV still remains a significant clinical problem. Palonosetron, a second-generation 5-HT3-RA, provides superior protection against both, nausea and vomiting, and demonstrated superior long-lasting CINV prevention in the delayed phase. Another recently approved agent is the NK1-RA fosaprepitant, which has shown equivalency in the prevention of both, acute and delayed CINV to aprepitant, and is used as a single day intravenous prophylaxis. This review provides an update of the revised clinical guidelines for antiemetic treatment and prophylaxis in cancer patients receiving chemotherapy.

Fischer, D.; Wedel, B.

2012 memo - Magazine of European Medical Oncology

doi: 10.1007/s12254-012-0327-2

Psycho-oncologist research in recent years has focused on assessment of distress and mental disorders in cancer patients. Primary objective has been the implementation of individually tailored psychosocial support during routine medical care. This review shows that based on validly structured clinical interviews, 30–40% of the studied patient population had a mental disorder in accordance with the updated Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Most common diagnoses were depression, adjustment and anxiety disorders. Risk factors included among others younger age, previous history of mental disorders and lack of social support. Screening instruments are useful, easy to complete and allow early detection of high distress in patients, enabling appropriate interventions in affected patients. Established methods in psycho-oncology are cognitive behavioural therapy, psycho-educational groups and relaxation trainings. A positive influence of early palliative care intervention on cancer patients' mood has been shown. Adequate resources in acute and outpatient routine care shall be offered.

Klocker, J.; Klocker-Kaiser, U.; Geissler, D.

2012 memo - Magazine of European Medical Oncology

doi: 10.1007/s12254-012-0343-2

Due to increasing numbers of cancer patients caused by both today's longer life expectancy and the drop in cancer mortality, the number of patients who have gone through cancer continuously increases. Such patients not only are often physically impaired and psychologically vulnerable but show also socio-economic adverse effects. Hence, efficient oncological rehabilitation is only possible when this complex situation is taken into account by approaching the following four aspects: (1) acceptance and handling of organic failures, (2) reassessment and lifestyle adjustments, (3) psychological stabilisation and (4) social and occupational reintegration. The current article gives a brief summary of the measures crucial for a successful oncological rehabilitation.

Bergmeister, P.; Gasser, K.; Lang, A.

2012 memo - Magazine of European Medical Oncology

doi: 10.1007/s12254-012-0328-1

With the increasing use of intravenous bisphosphonates in oncological settings, osteonecrosis of the jaw is now a more common and often devastating complication which, in an advanced stage, significantly impacts the quality of life. Since management and therapy of osteonecrosis present major challenges, more attention should be focused on the assessment of risk and preventive measures. In recent years bisphosphonate treatment, especially its intravenous application, has been identified as the main cause of osteonecrosis of the jaw. However, denosumab, a novel and promising agent in treating metastatic bone disease and osteoporosis, also increases risks. With coincidental trigger factors such as dental extractions and antiresorptive therapy with either intravenous bisphosphonate or denosumab there is an estimated one to ten per cent risk of subsequently developing osteonecrosis of the jaw. Although several theoretical concepts on the pathogenesis and natural history of bisphosphonate-related osteonecrosis have been presented, a definitive cause-and-effect relationship is missing. Bisphosphonates have effects on immune function, bone remodelling, wound healing and angiogenesis. These mechanisms, in combination with the jaw's vulnerability, might explain its inability to deal with mucosal or bone damage. With a clearer understanding and increasing awareness in the oncology community several other drugs, especially the anti-angiogenic agents bevacizumab and sunitinib are being seriously suspected of inducing osteonecrosis, or at least increasing the risk, in combination or following therapies with bisphosphonates or denosumab.

Troch, M.; Kiesewetter, B.; Raderer, Markus

2012 memo - Magazine of European Medical Oncology

doi: 10.1007/s12254-012-0339-y

Neuroendocrine tumours (NETs) are rare tumours with their clinical behaviour depending on the location of the primary and grade of differentiation. Recently, a number of randomised studies have been published focussing on pancreatic NETs which have demonstrated the efficacy of new therapeutic approaches including thyrosin-kinase inhibition and targetting the mTOR pathway. The objective of this review is to briefly sum up systemic treatment options in well differentiated pancreatic neuroendocrine tumours which are currently available.

Simanek, R.; Henry, A.; Weixler, D.; Hammerl-Ferrari, B.; Geissler, K.; Watzke, H.

2012 memo - Magazine of European Medical Oncology

doi: 10.1007/s12254-012-0342-3

The effect of parenteral nutrition (PN) in advanced cancer patients is exemplified at the clinical case of a male, 82-year old patient. Methods: Case report and short survey of the current literature. Results: In our patient with locally advanced pancreatic cancer, inflammatory state and recurrent ascites/oedema due to an anorexia-cachexia-syndrome, persistent symptom control could be reached by antiinflammatory treatment and supplemental PN until his death.