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Introduction Few available data indicate that a mutation-based “neoadjuvant” therapy in advanced anaplastic thyroid carcinoma (ATC) might convert an initially unresectable primary tumor to resectable and optimize local tumor control. We evaluated a preoperative short-term “neoadjuvant” therapy with a BRAF-directed therapy or, in case of BRAF non-mutated tumors, an mKI/checkpoint inhibitor combination in three patients with ATC stage IVB and C. Methods In the context of preoperative diagnostics, immunohistochemistry (IHC) assessment and genetic analysis was started as soon as possible. The antiangiogenetic therapy with lenvatinib was immediately after diagnosis of ATC started as bridging therapy. In case of a BRAF-mutated ATC, a combination therapy of dabrafenib and trametinib, in case of BRAF-wildtype ATC a combination of pembrolizumab and lenvatinib was given for 4 weeks. If re-staging has shown a significant therapy response due to a decrease in size of > 50%, surgical resection was reconsidered. A primary tumor resection was performed first. As a second step, limited distant metastasis have been resected approximately 4 weeks after thyroid surgery. After postoperative recovery, the targeted systemic therapy was continued. Patients Two patients presented with BRAF-wildtype ATC stage IVC, one with BRAF-mutated ATC stage IVB. All patients were evaluated by surgery, nuclear medicine and oncology upon diagnosis of ATC. Results In all three cases, the “neoadjuvant” therapy induced a dramatic response and led to local resectability in primarily non-resectable ATC stage IVB or C. We have chosen for the first time a short-term “neoadjuvant” treatment period to reduce the risk of bleeding and/or fistula due to potential rapid tumor shrinkage. The results of surgery after only short-term “neoadjuvant” therapy showed two R0 und one R1 resections. Postoperative histopathological findings confirmed an extent of tumor necrosis or regressive fibrotic tissue between 60 and > 95% in our patients. Conclusions A short-term mutation-based “neoadjuvant” therapy can achieve local resectability in initially unresectable ATC stage IVB or C. A neoadjuvant treatment period of about 4 weeks seems to show similar response as a treatment duration of at least 3 months.

Purpose Patients with advanced cancer often receive suboptimal end-of-life (EOL) care. Particularly males with advanced cancer are more likely to receive EOL care that is more aggressive, even if death is imminent. Critical factors determining EOL care are EOL conversations or advance care planning. However, information about gender-related factors influencing EOL conversations is lacking. Therefore, the current study investigates gender differences concerning the content, the desired time point, and the mode of initiation of EOL conversations in cancer patients. Methods In a cross-sectional study, 186 female and male cancer patients were asked about their preferences for EOL discussions using a semi-structured interview, focusing on (a) the importance of six different topics (medical and nursing care, organizational, emotional, social, and spiritual/religious aspects), (b) the desired time point, and (c) the mode of discussion initiation. Results The importance of EOL topics differs significantly regarding issue (p = 0.002, η2 = 0.02) and gender (p η2 = 0.11). Males wish to avoid the engagement in discussions about death and dying particularly if they are anxious about their end-of-life period. They wish to be addressed regarding the “hard facts” nursing and medical care only. In contrast, females prefer to speak more about “soft facts” and to be addressed about each EOL topic. Independent of gender, the majority of patients prefer to talk rather late: when the disease is getting worse (58%), at the end of their therapy, or when loosing self-sufficiency (27.5%). Conclusion The tendency of patients to talk late about EOL issues increases the risk of delayed or missed EOL conversations, which may be due to a knowledge gap regarding the possibility of disease-associated incapability. Furthermore, there are significant gender differences influencing the access to EOL conversations. Therefore, for daily clinical routine, we suggest an early two-step, gender-sensitive approach to end-of-life conversations.

Trifluridine/tipiracil (FTD/TPI) improved both overall and progression-free survival (OS, PFS) of patients with pre-treated metastatic colorectal cancer (mCRC) in the pivotal phase III RECOURSE trial. However, health-related quality of life (HRQoL) was not assessed directly. To this end and to generate post-authorisation data, the TALLISUR trial was conducted.In this prospective, multi-centre, Germany-wide, phase IV study, patients with pre-treated mCRC were given the choice to receive either FTD/TPI or best supportive care (BSC). A validated questionnaire, EORTC QLQ-C30, was employed to assess HRQoL. Secondary endpoints included OS, PFS and safety.Of 194 eligible patients, 185 decided to receive FTD/TPI and 9 to receive BSC. The low number of patients in the BSC-arm did not allow statistically meaningful analyses. On the other hand, treatment with FTD/TPI was associated with maintained HRQoL. Median OS was 6.9 months [95% confidence interval (CI) 6.1-8.2 months] and median PFS was 2.5 months (95% CI 2.1-2.9 months). The most frequent treatment-emergent adverse events were neutropenia (27.6%) and anaemia (22.7%). Febrile neutropenia occurred in 1.1%.Treatment of patients suffering from pre-treated mCRC with FTD/TPI was associated not only with prolonged survival and delayed progression but also with maintained HRQoL.

Background Implementation of advance care planning (ACP) is proceeding in the western world and often recognised as a sufficient approach to ensure patients’ wishes for end of life (EoL) care. There is evidence that patient related outcomes are improved. However, information about the impact of ACP on quality of life (QoL) in palliative cancer patients is missing. Methods This randomised controlled trial investigates the efficacy and effectiveness of a collaborative ACP (cACP) intervention in palliative cancer patients and their care givers by comparing three groups: 1. cACP-Intervention; 2. Supportive intervention 3. Treatment as usual. The cACP-intervention consists of four sessions (two with the patient alone, one with the care giver alone, one together) that address potential barriers to discuss end of life issues (e.g. negative expectations concerning EoL issues and ACP) and two regular ACP sessions. Primary endpoint is the patient health-related QoL (FACIT-PAL). Secondary endpoints are general QoL; distress; acceptance; depressiveness; evaluation of the intervention; care-givers: heath-related and general QoL. Patients’ QoL is evaluated every second month for one year. In the event of the patients death, care-givers are asked to answer questions about concordance of advance care planning with actual care and the patients quality of dying. Results Until 11/18, 75 patients have been randomized, 13 patients finished the intervention, 21 patients died, denial rate is at approx. 55%. Conclusion This study tries to implement ACP in a palliative cancer setting in Germany. The efficacy and effectiveness of a novel collaborative ACP intervention are evaluated.

Background Males receive more aggressive care near death. End-of-life (EOL) conversations can protect from aggressive care near death and support more consistent EOL care. Therefore, information about gender effects on engagement in and realization of EOL conversations are needed. Methods In a cross-sectional study 186 cancer patients from an university and rehab hospital were asked about their preferences for EOL discussions using a semi-structured interview, focusing on a) the importance of six different EOL issues (medical and nursing care, organizational, emotional, social and spiritual/religious aspects), b) the desired time point, c) mode of discussion initiation. Results The importance of EOL topics differ significantly by issue (p=.002, η2=.02) and gender (p Conclusion Because of distinct gender differences for engagement in and realization of EOL conversations a gender sensitive approach is recommended. Independent of gender, the tendency of patients to talk late about EOL issues should be considered to reduce the risk of delayed or neglected EOL conversations. Therefore, a two-step approach of end-of-life conversations is suggested.

Background The immune surveillance reactivator lefitolimod (MGN1703), a DNA-based TLR9 agonist, might foster innate and adaptive immune response and thus improve immune-mediated control of residual cancer disease. The IMPULSE phase II study evaluated the efficacy and safety of lefitolimod as maintenance treatment in extensive-stage small-cell lung cancer (ES-SCLC) after objective response to first-line chemotherapy, an indication with a high unmet medical need and stagnant treatment improvement in the last decades. Patients and methods 103 patients with ES-SCLC and objective tumor response (as per RECIST 1.1) following four cycles of platinum-based first-line induction therapy were randomized to receive either lefitolimod maintenance therapy or local standard of care at a ratio of 3 : 2 until progression or unacceptable toxicity. Results From 103 patients enrolled, 62 were randomized to lefitolimod, 41 to the control arm. Patient demographics and response patterns to first-line therapy were balanced. Lefitolimod exhibited a favorable safety profile and pharmacodynamic assessment confirmed the mode-of-action showing a clear activation of monocytes and production of interferon-gamma-induced protein 10 (IP-10). While in the intent-to-treat (ITT) population no relevant effect of lefitolimod on progression-free and overall survival (OS) could be observed, two predefined patient subgroups indicated promising results, favoring lefitolimod with respect to OS: in patients with a low frequency of activated CD86+ B cells (hazard ratio, HR 0.53, 95% CI: 0.26–1.08; n = 38 of 88 analyzed) and in patients with reported chronic obstructive pulmonary disease (COPD) (HR 0.48, 95% CI: 0.20–1.17, n = 25 of 103). Conclusions The IMPULSE study showed no relevant effect of lefitolimod on the main efficacy end point OS in the ITT, but (1) the expected pharmacodynamic response to lefitolimod, (2) positive OS efficacy signals in two predefined subgroups and (3) a favorable safety profile. These data support further exploration of lefitolimod in SCLC.

Background This trial evaluated activity and safety of mFOLFOXIRI + panitumumab (P) vs FOLFOXIRI in ECOG 0-1, primarily non-resectable mCRC patients. Here, we report the quality of life data. Methods Prospective 2:1 randomized, phase II trial comparing mFOLFOXIRI (Ox 85 mg/m2, Iri 150 mg/m2, 5FU 3000mg/m2 cont. 48h, LV 200 mg/m2) + P 6 mg/KG (arm A) with FOLFOXIRI (Ox 85 mg/m2, Iri 165 mg/m2, 5FU 3200mg/m2 cont. 48h, LV 200 mg/m2; arm B), both arms q2w. Cohort 1: irresectable mCRC; cohort 2: chance of secondary resection of metastatic lesions. Primary endpoint was ORR, secondary endpoints were secondary resection rate (cohort 2), toxicity, quality of life (QoL, QLQ-C30). Between-treatment differences in QoL were assessed from baseline to disease progression, and to discontinuation of 1st-line treatment, using analysis of covariance (ANCOVA). Results A total of 96 patients were randomized (63 arm A, 33 arm B). There were significantly higher ORR (87.3% vs. 60.6%, p = 0.004), ETS (85.7% vs 60.0%, p = 0.01) and DpR (58.9% vs. 40.9%) in the P arm compared to FOLFOXIRI alone. QoL analyses was performed in 51 patients in arm A and 26 patients in arm B. There were no statistically significant differences between treatment arms from baseline to progression or to discontinuation. Although significantly more secondary resections of metastases were achieved in the P arm of cohort 2 (75.0% vs. 36.4%, p = 0.05), QoL was not different between cohorts 1 and 2 and the treatment arms, respectively. Toxicity or patient wish as the reason for end of therapy were not different between the treatment arms A and B (12.7% vs. 21.2% and 0% vs 6.1%, respectively). Grade III/IV toxicities were numerically higher in the P arm (81.3% vs. 66.7%). This increase was mainly due to toxicities such as diarrhea (25.0% vs 12.1%), mucositis (9.4 vs. 0%), rash (14.1% vs. 0%), and fatigue (7.8% vs. 0%). Conclusions mFOLFOXIRI plus P results in significantly higher response rates compared to FOLFOXIRI in RAS wild-type mCRC. Although toxicity was increased, QL reporting was similar in both arms. Therefore, intensive upfront therapy with modified FOLFIRINOX+P represents a valuable treatment option in patients with the need of a highly active 1st-line therapy. Clinical trial identification NCT01328171. Legal entity responsible for the study Arbeitsgemeinschaft Internistische Onkologie (AIO). Funding Amgen. Disclosure M. Geissler: Honoraria (institution), Advisory / Consultancy: Amgen. D. Modest: Honoraria (institution), Advisory / Consultancy: Amgen. V. Heinemann: Honoraria (institution), Advisory / Consultancy: Amgen. All other authors have declared no conflicts of interest.

Background The majority of patients (pts) with gastroesophageal cancer present with inoperable or metastatic disease and there is a strong need for efficient and tolerable first-line (1L) treatment. Oxaliplatin-based regimens like FOLFOX have become one standard of care. However, median survival is still below 12 months. Results from trials using nivolumab plus ipilimumab treatment of subjects with advanced/metastatic GC and GEJ cancers demonstrated clinical activity, in pts whose tumors did or did not express PD-L1; in addition, nivolumab alone and in combination with ipilimumab demonstrated clinical benefits in various other tumor types. Based on this clinical experience, the AIO-STO-0417 trial (Moonlight) has been designed to evaluate the combination of chemotherapy with two checkpoint inhibitors in first-line therapy of pts with gastroesophageal adenocarcinoma. Trial design This is a prospective, multicenter, randomized, investigator-initiated phase II trial. Pts with Her2-negative, inoperable, advanced or metastatic gastric or esophagogastric junction cancer will be randomized 1:1 to 1L treatment with FOLFOX (Oxaliplatin 85 mg/m²; Leucovorin 400 mg/m²; 5FU 400 mg/m² on d1 of each treatment cycle and 5FU 2400 mg/m² continuous infusion over 44 hrs) every 2 weeks plus Nivolumab 240 mg every 2 weeks and Ipilimumab 1mg/kg every 6 weeks (Arm A) or FOLFOX alone (Arm B). Primary endpoint of the trial is progression-free survival based on the ITT population. Main secondary endpoints are overall survival, objective response rate, Safety and Quality of life (EORTC QLQ-C30). 118 pts (59 per arm) will be enrolled to provide 80% power for detecting an average HR of 0.68 using the log rank test at a one-sided type I error of 10%. At the date of submission (May 2019), 45 of planned 118 pts are randomized. Clinical trial identification NCT03647969. Legal entity responsible for the study IKF Klinische Krebsforschung GmbH am Krankenhaus Nordwest. Funding Bristol-Myers Squibb. Disclosure S. Lorenzen: Honoraria (self), Advisory / Consultancy, Research grant / Funding (self): Lilly; Advisory / Consultancy: Servier; Advisory / Consultancy: Sanofi; Advisory / Consultancy: MSD; Advisory / Consultancy: Celgene. T.O. Goetze: Advisory / Consultancy, Speaker Bureau / Expert testimony: Lilly; Advisory / Consultancy, Speaker Bureau / Expert testimony: MSD; Advisory / Consultancy: Shire; Advisory / Consultancy: Bayer; Advisory / Consultancy: Celgene; Advisory / Consultancy: Servier; Speaker Bureau / Expert testimony: MCI Group; Research grant / Funding (self), Research grant / Funding (institution): German Research Foundation. E. Goekkurt: Advisory / Consultancy: MSD Oncology; Advisory / Consultancy: Roche; Advisory / Consultancy: Sanofi; Advisory / Consultancy: Pfizer; Advisory / Consultancy: Bristol-Myers Squibb; Advisory / Consultancy: Merck Serono; Travel / Accommodation / Expenses: Servier. T.J. Ettrich: Advisory / Consultancy: Merck; Advisory / Consultancy: Sanofi; Advisory / Consultancy: Sirtex Medical; Advisory / Consultancy: Novartis; Advisory / Consultancy: Bayer; Advisory / Consultancy: Bristol-Myers Squibb; Advisory / Consultancy: Pfizer; Advisory / Consultancy: Merck Serono; Travel / Accommodation / Expenses: Ipsen; Research grant / Funding (self): Baxalta. N. Homann: Advisory / Consultancy, Speaker Bureau / Expert testimony: Sanofi; Advisory / Consultancy, Speaker Bureau / Expert testimony: Roche; Advisory / Consultancy, Speaker Bureau / Expert testimony: Amgen; Advisory / Consultancy: Lilly; Advisory / Consultancy, Speaker Bureau / Expert testimony: Servier; Advisory / Consultancy: Bristol-Myers Squibb; Speaker Bureau / Expert testimony: Celgene; Speaker Bureau / Expert testimony: MSD; Speaker Bureau / Expert testimony: Merck. P.C. Thuss-Patience: Advisory / Consultancy, Travel / Accommodation / Expenses: Roche; Advisory / Consultancy: MSD; Advisory / Consultancy: Nordic Bioscience; Advisory / Consultancy, Travel / Accommodation / Expenses: Lilly; Advisory / Consultancy: Pfizer; Advisory / Consultancy, Travel / Accommodation / Expenses: Bristol-Myers Squibb; Advisory / Consultancy, Travel / Accommodation / Expenses: Merck; Research grant / Funding (self): Novartis; Travel / Accommodation / Expenses: Teva; Travel / Accommodation / Expenses: Astellas Korea. H. Schmalenberg: Honoraria (self), Advisory / Consultancy, Speaker Bureau / Expert testimony: Novartis; Honoraria (self), Advisory / Consultancy, Speaker Bureau / Expert testimony, Travel / Accommodation / Expenses: Lilly; Honoraria (self), Advisory / Consultancy: MSD; Honoraria (self), Advisory / Consultancy, Speaker Bureau / Expert testimony: Servier; Research grant / Funding (self): Archigen. R.D. Hofheinz: Honoraria (self), Advisory / Consultancy: Bristol-Myers Squibb. S. Al-Batran: Advisory / Consultancy, Speaker Bureau / Expert testimony, Research grant / Funding (self), Research grant / Funding (institution): Roche; Advisory / Consultancy, Speaker Bureau / Expert testimony, Research grant / Funding (self), Research grant / Funding (institution): Celgene; Advisory / Consultancy, Speaker Bureau / Expert testimony, Research grant / Funding (self), Research grant / Funding (institution): Lilly; Advisory / Consultancy: Bristol-Myers Squibb; Advisory / Consultancy, Research grant / Funding (self), Research grant / Funding (institution): Merck; Advisory / Consultancy, Speaker Bureau / Expert testimony: Nordic Bioscience; Advisory / Consultancy: Merck Sharp and Dohme; Leadership role, Shareholder / Stockholder / Stock options: IKF Klinische Krebsforschung GmbH; Speaker Bureau / Expert testimony: AIO gGmbH; Speaker Bureau / Expert testimony: Forum fur Medizinische Fortbildung; Speaker Bureau / Expert testimony: MCI group; Speaker Bureau / Expert testimony: promedicis; Research grant / Funding (self), Research grant / Funding (institution): Medac; Research grant / Funding (self), Research grant / Funding (institution): Hospira; Research grant / Funding (self), Research grant / Funding (institution): Sanofi; Research grant / Funding (self), Research grant / Funding (institution): German Cancer Aid; Research grant / Funding (self), Research grant / Funding (institution): German Research Foundation; Research grant / Funding (self), Research grant / Funding (institution): Federal Ministry of Education and Research of Germany; Research grant / Funding (self), Research grant / Funding (institution): Vifor Pharma. All other authors have declared no conflicts of interest.

Doppler ultrasound is a well established method for assessment of the portal venous system to detect the direction of portal blood flow. It is helpful for non-invasive diagnosis of intra-abdominal portosystemic shunts, especially in patients with cirrhosis. Less attention has been paid to other influences on portal venous flow, e.g. tricuspid regurgitation, increased hepatic out-flow resistence, respiratory cycle. The aim of this pictorial review is to describe the spectrum of physiological and pathological Doppler ultrasound flow patterns in the portal venous system.

Background: Evaluation of the SPIKES protocol, a recommended guideline for breaking bad news, is sparse, and information about patients’ preferences for bad-news delivery in Germany is lacking. Being the first actual–theoretical comparison of a ‘breaking bad news’ guideline, the present study evaluates the recommended steps of the SPIKES protocol. Moreover, emotional consequences and quality of bad-news delivery are investigated. Patients and methods: A total of 350 cancer patients answered the MABBAN (Marburg Breaking Bad News Scale), a questionnaire representing the six SPIKES subscales, asking for the procedure, perception and satisfaction of the first cancer disclosure and patient’s assign to these items. Results: Only 46.2% of the asked cancer patients are completely satisfied with how bad news had been broken to them. The overall quality is significantly related to the emotional state after receiving bad news (r= −0.261, P < 0.001). Patients’ preferences differ highly significantly from the way bad news were delivered, and the resulting rang list of patients’ preferences indicates that the SPIKES protocol do not fully meet the priorities of cancer patients in Germany. Conclusions: It could be postulated that the low satisfaction of patients observed in this study reflects the highly significant difference between patients’ preferences and bad-news delivery. Therefore, some adjunctions to the SPIKES protocol should be considered, including a frequent reassurance of listeners’ understanding, the perpetual possibility to ask question, respect for prearrangement needs and the conception of bad-news delivery in a two-step procedure.

Functional hyposplenia/asplenia is a severe longterm complication after allogeneic stemcell transplantation predominantly seen in patients who suffer from extensive chronic graft versus host disease (cGvHD). The risk of acquiring an overwhelming infection with encapsulated bacteria is ca. four fold increased in patients with functional hyposplenia/asplenia. Therefore follow up of patients who have received allogeneic blood stem cells (bone marrow or peripheral blood stem cells) should embrace screening for functional hyposplenia. When functional hyposplenia is diagnosed triple vaccination against streptococcus pneumonia, Haemophilus influenza type B and Meningococcus neisseria should be considered. Goldstandard in diagnosing functional hyposplenia is hepatosplenic scintigraphy. We present the case of 37 year old female in whom sonography was indicative of functional hyposplenia. The diagnosis was confirmed by scintigraphy. Sonography including color coded duplex sonography is a safe and cost saving procedure. Sensitivity, Specificity and predictive value of the following sonographic finding: a) decreasing splenic size and b) diminished or absent parenchymal blood flow are currently evaluated in a prospective study.

Aim The aim of our study was to describe clinical data, frequency of the findings, sonographic patterns, confirmation of diagnosis, and differential diagnosis of focal echorich splenic lymphoma involvement. Patients During the last 20 years a focal splenic lesion was found in 178 patients with malignant lymphoma. Echorich splenic lesions were seen in 11 out of 178 cases (6.2%). Methods Splenic size, echomorphology of lesions, size and number of lesions, and presentation during sonographic follow-up examination were presented. Results Echorich infiltrates of the spleen were predominantly seen in patients with low grade Non-Hodgkin-Lymphoma (9 out of 11), the size of lesions mostly was less than 3 cm in diameter (9 out of 11), the underlying splenic size was over 8 x 20 cm in 9 out of 11 patients. Diagnosis was confirmed by sonographic follow-up (n = 11) and autopsy (n = 1). Conclusion Echorich splenic lymphoma involvement is a rare event and is characterised by a variable presentation during follow-up. Up to date the clinic significance of our observation is still unclear.

ML18147 evaluated continued bevacizumab with second-line chemotherapy for patients with metastatic colorectal cancer (mCRC) progressing after the standard first-line bevacizumab-containing therapy.Evaluating outcomes according to tumor Kirsten rat sarcoma virus oncogene (KRAS) status was an exploratory analysis. KRAS data were collected from local laboratories (using their established methods) and/or from a central laboratory (mutation-specific Scorpion amplification-refractory mutation system). No adjustment was made for multiplicity; analyses were not powered to detect statistically significant differences.Of 820 patients, 616 (75%) had unambiguous KRAS data; 316 (51%) had KRAS wild-type tumors and 300 (49%) had mutant KRAS tumors. The median progression-free survival (PFS) was 6.4 months for bevacizumab plus chemotherapy and 4.5 months for chemotherapy [P0.0001; HR = 0.61; 95% confidence interval (CI): 0.49-0.77] for wild-type KRAS and 5.5 and 4.1 months, respectively (P = 0.0027; HR = 0.70; 95% CI: 0.56-0.89) for mutant KRAS. The median overall survival (OS) was 15.4 and 11.1 months, respectively (P = 0.0052; HR = 0.69; 95% CI: 0.53-0.90) for wild-type KRAS and 10.4 versus 10.0 months, respectively (P = 0.4969; HR = 0.92; 95% CI: 0.71-1.18) for mutant KRAS. In both analyses, no treatment interaction by KRAS status was observed (PFS, P = 0.4436; OS, P = 0.1266).Bevacizumab beyond first progression represents an option for patients with mCRC treated with bevacizumab plus standard first-line chemotherapy, independent of KRAS status.

Background Patients end of life decisions (EOLD) are needed to be known in time to respect patient’s choices and to realise consistent end-of-life care. However, it is known that EOL topics are addressed often late, leading to delayed EOLD discussions followed by inconsistent EOL care. Aim To evaluate patient’s preferences of how and when EOLD communications should occur. Methods 89 patients with palliative stage advanced cancer were asked about their preferences concerning EOL conversations using a semi-structured interview. The interview focused on the importance patients gave to different end of life topics, the desired time point of the conversation and the mode of discussion initiation. Results The results showed significant differences in the importance of EOL topics, F (4.3, 354.0) = 22.96, p Conclusion To respect patients preferences and overcome the dilemma of delayed EOL conversations a splitting of EOL conversations into two parts could be suggested: Focused “early” conversations about the course of the disease, handing all information concerning the necessity of EOL(D) conversations and the potential of cognitive impairment and serious crises, and depended on patients decision, an optionally later discussions focus on EOLD and more personal EOL aspects.

Background Little is known about potential different preferences between patients and their family members concerning content and timing of end of life decisions (EOLD) discussions. Aim To gain more information about patients and their family members desires for EOLD discussion. Methods We conducted a semi-structured interview with 89 palliative cancer patients and 68 of their family members. We asked them to rate the importance of six main topics (scale 1–10) and to choose their preferred timing (scale 1–3). Differences were analysed using the Mann-Whitney test. Results In both groups “medical care” seemed to be the main topic, particularly for family members (M = 9,21, SD ±1,33; z = –2,86; p Conclusion The difference between the two groups in content and timing of conversations was larger than previously expected. “Medical care” and “nursing care” seem to be important for both groups, but while “medical care” should be discussed earlier, it seems that “nursing care” is only a topic of interest, when the general condition deteriorated. Interestingly, the topic “feelings” differed significantly between both groups and should be considered in EOLD discussions with family members.

Doppler ultrasound is a well established method for assessment of the portal venous system to detect the direction of portal blood flow. It is helpful for non-invasive diagnosis of intra-abdominal portosystemic shunts, especially in patients with cirrhosis. Less attention has been paid to other influences on portal venous flow, e.g. tricuspid regurgitation, increased hepatic out-flow resistance, respiratory cycle. The aim of this pictorial review is to describe the spectrum of physiological and pathological Doppler ultrasound flow patterns in the portal venous system.

We describe respiration-dependent reversed flow in the splenic vein detected by color Doppler sonography in 2 patients. In case 1, gray-scale sonography in a patient with liver cirrhosis and abdominal pain showed a hyperechoic, thickened colonic segment and diverticula, with increased echogenicity around the diseased colon. The liver was small, with a nodular surface and coarse echotexture. Doppler sonography of the portal and splenic veins showed a constant hepatopetal flow while the patient held her breath in midinspiration and a brief, transient color change restricted to the hilar splenic veins when the patient took a deep breath. In case 2, abdominal sonography in a patient with pneumonia and right-sided abdominal pain showed mural thickening of the appendix and left-sided pneumonic infiltration. The liver size and texture were normal. Color Doppler sonography of the portal and splenic veins showed a constant hepatopetal flow while the patient held his breath in midinspiration and a transient reversal of flow restricted to the splenic veins when the patient took a deep breath. Although the cause of this flow pattern is unclear, increased intra-abdominal pressure is a possible explanation.

Functional hyposplenia/asplenia is a severe longterm complication after allogeneic stemcell transplantation predominantly seen in patients who suffer from extensive chronic graft versus host disease (cGvHD). The risk of acquiring an overwhelming infection with encapsulated bacteria is ca. four fold increased in patients with functional hyposplenia/asplenia. Therefore follow up of patients who have received allogeneic blood stem cells (bone marrow or peripheral blood stem cells) should embrace screening for functional hyposplenia. When functional hyposplenia is diagnosed triple vaccination against streptococcus pneumonia, Haemophilus influenza type B and Meningococcus neisseria should be considered. Goldstandard in diagnosing functional hyposplenia is hepatosplenic scintigraphy. We present the case of 37 year old female in whom sonography was indicative of functional hyposplenia. The diagnosis was confirmed by scintigraphy. Sonography including color coded duplex sonography is a safe and cost saving procedure. Sensitivity, Specificity and predictive value of the following sonographic finding: a) decreasing splenic size and b) diminished or absent parenchymal blood flow are currently evaluated in a prospective study.

We report on 2 patients with hematologic diseases (1 follicular lymphoma and 1 myeloproliferative syndrome) and splenomegaly who had partial intrasplenic portosystemic shunting demonstrated by color Doppler sonography. Intrasplenic venous blood flow was in the normal direction at the hilum of the spleen but in a reversed direction at the periphery of the spleen. This type of reversed intrasplenic flow pattern results in portosystemic shunting and might be detected more frequently when careful color Doppler mapping of the entire splenic parenchyma is performed in patients with portal hypertension. The clinical significance of this phenomenon, however, is still unclear.

The aim of our study was to describe clinical data, frequency of the findings, sonographic patterns, confirmation of diagnosis, and differential diagnosis of focal echorich splenic lymphoma involvement.During the last 20 years a focal splenic lesion was found in 178 patients with malignant lymphoma. Echorich splenic lesions were seen in 11 out of 178 cases (6.2%).Splenic size, echomorphology of lesions, size and number of lesions, and presentation during sonographic follow-up examination were presented.Echorich infiltrates of the spleen were predominantly seen in patients with low grade Non-Hodgkin-Lymphoma (9 out of 11), the size of lesions mostly was less than 3 cm in diameter (9 out of 11), the underlying splenic size was over 8 x 20 cm in 9 out of 11 patients. Diagnosis was confirmed by sonographic follow-up (n = 11) and autopsy (n = 1).Echorich splenic lymphoma involvement is a rare event and is characterised by a variable presentation during follow-up. Up to date the clinic significance of our observation is still unclear.

4511 Background: Perioperative treatment is common in localized adenocarcinomas of the upper GI-tract. By now, there is no randomized data about the contribution of preoperative radiotherapy additional to chemotherapy. Methods: Based on phase II results of our group we targeted 394 patients to test whether chemoradiation will increase the 3-year survival rate by 10% compared with chemotherapy. Patients with stage T3–4 NX M0 according to EGD, EUS, CT and laparoscopy were included. Patients were randomized to treatment with either (arm A) 2.5 courses of chemotherapy (cisplatin 50mg/m2, d 1,15,29, folinic acid 500 mg/m2 and 5-FU 2g/m2 24h-infusion, weekly times 6, qd 49 or (arm B) 2 courses of the same chemotherapy followed by three weeks of chemoradiotherapy (30 Gy, cisplatin 50 mg/m2 d 2+8 and etoposide 80 mg/m2 d 3–5). Epoetin alpha was recommended to keep the hemoglobin above 12.5 g/dl. Tumor resection was planned 3 to 4 weeks after the end of preoperative therapy for both groups. Results: A total of 126 patients were randomized into the study between 12/00 and 12/05 when the trial was closed due to poor accrual. 120 pts. were eligible (CTX 60, CRTX 60). The toxicitiy of CTX was low. Severe leucocytopenia and thrombocytopenia was 35% and 16%, respectively during CRTX. Until 12/06 ninety pts. underwent surgery and had complete reports. A complete resection was possible in 77% and 85% of operated pts. in arm A and arm B, respectively. The rate of complete histologic response was 2.5% after CTX and it reached 17% after CRTX (p=0.06). Despite increased postoperative mortality after chemoradiotherapy (5 vs. 2 pts.) the median survival time (32.8 mo) and the 3- year survival rate (43%) were improved in this patients group compared with patients of arm A (21.1 mo, 27%)(logrank p=0.14). Conclusions: This randomized study demonstrates that albeit its increased mortality preoperative chemoradiotherapy appears to prolong survival compared with preoperative chemotherapy in locally advanved esophago-gastric adenocarcinomas. Although accrual was below that planned, the observed difference in survival is clinically important and calls for further randomized trials in patients with this disease. No significant financial relationships to disclose.