A B S T R A C T S
a 1200 bed teaching hospital in the Netherlands. Data on
epidural and surgical techniques, ASA (American Society of
Anesthesiologists) and ISAR-HP (Identification of Seniors
at Risk) scores, epidural failure, need for perioperative
vasopressors, length of stay and complicationswere evaluated.
Our study included 27 patients undergoing
29 operations, for breast cancer under thoracic epidural
anesthesia between 8-2013 and 11-2015. The mean age was 85
years [range: 70-94]. Eight patients underwent a mastectomy,
20 a lumpectomy and 1 reoperation was performed because
of a post-operative breast hematoma. Three patients had an
ASA-score of I (11%), 10 (37%) of II, 13 (48%) of III and 1 (4%)
of IV. The mean ISAR-HP score was 3.3. In 67% a preoperative
consultation by a geriatrician was performed.
The epidural catheter was placed between T
epidural anesthesia typically required 10 ml of ropivacaine
0.75%. In 3 patients (10%) the epidural access failed; 2 patients
received a paravertebral block, in the other case surgery
was performed under sedation in combination with local
infiltration by the surgeon with ropivacaine 0.2%.
Most patients developed some degree of hypotension
due to sympathetic block, caused by the epidural analgesia.
More than 80% of patients received intravenous vasopressors
norepinephrine or phenylephrine, hemodynamics remained
stable with this treatment. In our retrospective study no
patients had clinically relevant hypotension. 58% received
light sedation with propofol or midazolam.
After surgery, the epidural catheter was removed in
the recovery room and pain was treated with minor oral
analgesics. The median stay in the hospital was 1 night [0-13].
In 2 of 25 patients (8%) delirium was diagnosed. Two patients
developed a hematoma after surgery requiring reoperation,
one patient received epidural anesthesia again. In the other
case, the hematoma developed after a warfarine-derivate
was starting due to newly diagnosed atrial fibrillation and
myocardial ischemia 2 days after surgery. She was not exposed
to hypotension during the primary breast surgery.
Thoracic epidural based anesthesia is feasible
and should be considered as a potentially optimal method
for breast cancer surgery in the frail elderly patient. Hence,
epidural anesthesia may give treatment options for patients
who do not prefer general anesthesia or previously were
excluded from surgery.
Disclosure of interest:
Breast surgery, complications, epidural
MAY THERAPEUTIC DRUG MONITORING OF 5FU DECREASE
TOXICITY IN ELDERLY? A RETROSPECTIVE STUDY
L. Bengrine Lefevre
*, V. Quipourt
, J. Vincent
, A. Cueff
, M. Deveaux
, S. Marilier
, F. Ghiringhelli
Medical oncology, Centre Georges François Leclerc,
Geriatric department, CHU Champmaillot,
department, Centre Georges François Leclerc,
EA 4184, Burgundy
UMR 866, INSERM,
Pharmacy department, Centre
Georges François Leclerc, Dijon, France
The clinical benefit of the use of 5FU in
monotherapy, doublet or triplet (with oxaliplatin and/or
irinotecan) is now recognized in patients with colorectal
or pancreatic cancer. However, in order to limit its toxicity,
in elderly, doses are frequently reduced by clinicians in an
empirical manner (i.e., without pharmacological rationale).
The objective of this study was to confirm that
therapeutic dose monitoring (TDM) of 5FU, based on Gamelin
et al. Methodology would help to decrease toxicity in elderly.
At Georges Francois Leclerc center in France,
all colorectal and pancreatic cancer patients (adjuvant
or metastatic disease) benefit of a 5FU concentration
measurement during the 46h infusion of the first cycle. The
aim is to rationally adapt the dose for the next cycles in
addition to side effects observed or described by the patient.
Exposures (Area Under the Curve, AUC) were derived from
those concentrations and compared to the therapeutic
window (i.e., 18 mg.h/L <AUC <28 mg.h/L). A lower or higher
AUC than expected gives the opportunity to the clinicians to
adapt 5FU dose according to a special algorithm. In this study,
we retrospectively analyzed dose adaptations for patients
above 70 years old, from April 1
2014 to February 1
Seventy-two patients (28 males and 44 females)
were included. Chemotherapy regimens were mainly FOLFOX
(34 patients) or FOLFIRI (14 patients). Most of patients are treated
on first line in metastatic disease. Forty percent of the AUC were
within the target AUC during the first cycle. Dose adaptation for
60% of patient is needed. Target AUC was obtained for 65.85%
of patient without increasing clinical toxicities. Six patients
experienced a grade 3 or higher toxicity during the first cycle
(i.e., 2 patients with grade 3 or 4 diarrhea, 1 patient with grade
3 neutropenia, 2 patients with grade 3 mucositis and 1 patient
with grade 4 neutropenia and mucositis). After dose adaptation,
only 2 patients experienced grade 3 neutropenia.
Therapeutic dose monitoring of 5FU may help
clinicians to optimize dose adaptation in elderly patients
for reduced toxicities. In particular, dose may be increased
without inflating toxicity for patient with no observed toxicity
on first cycle and could be rationally decreased in patient
with toxicity. Others studies are needed to correlate this
adjustement to chemotherapy efficacy.
 Gamelin et al. Individual Fluorouracil Dose Adjustment
Based on Pharmacocinetic Follow-up Compared With
Conventional Dosage: Results of a Multicenter Randomized
Trial of Patients with metastatic Colorectal Cancer. J of Clin
Oncol 2008; 13: 2099-2105.