Background: Radiation-induced necrosis is a complication of brain irradiation. Treatment options are limited. Methods: The response to treatment with low-dose bevacizumab in 2 patients with radiation-induced necrosis was reported. Results: Both patients with metastatic melanoma, aged 48 and 51 years, had significant symptomatic and radiological improvement with low-dose bevacizumab treatment. Doses as low as 5 mg/kg every 6 weeks and 7.5 mg/kg i.v. every 4 weeks were used and were highly effective. Conclusions: Low-dose bevacizumab is a solid option in the management of edema associated with radiation necrosis.

e15176 Background: Few data regard efficacy and safety of FOLFIRINOX (oxaliplatin 85 mg/m2, irinotecan 180 mg/m2, fluorouracil bolus of 400 mg/m2 and continuous infusion of 2400 mg/m2 over 46 hours and leucovorin 400 mg/m2) in patients over 65 years with advanced pancreatic adenocarcinoma. Methods: After Ethical Committee approval, consecutive patients age over 65 with biopsy proven pancreatic adenocarcinoma that received at least one cycle of modified dose-attenuated FOLFIRINOX (no bolus FU and reduced dose of at least one agent since first cycle) were selected (São José Hospital database) for a retrospective review for safety, response, and survival. Results: Nineteen consecutive patients were selected from our database. Patients characteristics included 12 (63,1%) males, 7 (36,9 %) females, median age 72,7 (range 66-79). Tumor location was 11 (57,8 %) head of the pancreas, 6 (31,57 %) body and 2 (11 %) in other sites. Grade 3/4 toxicities were reported in 10 patients (52,6 %): nausea/vomiting 1 (5,2 %), diarrhea 1 (5,2 %), fatigue 3 (15,7%), neutropenia 4 (21 %), thrombocytopenia 1 (5,2%) and febrile neutropenia 3 (15,6 %). Elevations in AST and ALT above the upper limit of normality were identified in 5 (26,31%). No deaths reported due to toxicity. Prophylactic granulocyte colony stimulator factor (G-CSF) was given to 14 (73 %). Seventeen patients completed at least four cycles; disease control was obtained in 15 (83, 3 %) with 1 complete response, 5 partial response and 9 stable diseases. Median reductions in doses in the first cycle of chemotherapy by drugs were: oxaliplatin 23,3 % (10%-30%), irinotecan 24,6 % (0%-60%), fluorouracil 20,6% (0%-40%). Median reductions in doses in the fourth cycle of chemotherapy by drugs were: oxaliplatin 20,8 % (0%-42%), irinotecan 24,9 % (0%-75%), fluorouracil 17,6% (0%-40%).With a median follow up of 4.5 months, median overall or progression free survival is not reached. Conclusions: Modified dose-attenuated FOLFIRINOX is a therapeutic option to elderly with advanced pancreatic adenocarcinoma. Although grade 3 and 4 toxicities were reported, they were manageable. Modified attenuated-dose of FOLFIRINOX needs further investigated.

RESUMO: Objetivo: Analisar o uso de antimicrobianos em enfermaria cirúrgica de hospital universitário terciário através de uma auditoria por um dia. Método: Em visita única, aleatória, à enfermaria cirúrgica, dados dos prontuários dos pacientes internados (pré e pós-operatórios) foram analisados. A prescrição de antimicrobianos foi qualificada como profilática, empírica, terapêutica com patógeno conhecido, terapêutica sem patógeno conhecido ou sem base racional, de acordo com critérios pré-estabelecidos. Resultados: Dos 50 pacientes internados, 46 eram pacientes cirúrgicos (N=46). Antibióticos foram prescritos para 13 indivíduos (28,3%). Associação de drogas foi utilizada em sete pacientes (53,8%). Dezenove antibióticos foram prescritos. Oito drogas (42,1%) foram usadas enquadrando-se entre as categorias empírica e sem base racional, quatro em cada. Seis drogas (31,6%) foram utilizadas para tratamento de infecção sem patógeno conhecido, três (15,7%) para tratamento de infecção com patógeno conhecido e duas drogas (10,5%) para profilaxia. Conclusão: Apesar de todas as preocupações com o uso racional dos antimicrobianos, na população estudada quase metade das drogas foi usada sem diagnóstico ou critério definido. A prescrição de antibióticos persiste tema atual. O assunto deve ser encarado com seriedade pelos cirurgiões, que devem saber quando indicar, como indicar e, ainda, quando não indicar (Rev. Col. Bras. Cir. 2008; 35(4): 216-220). ABSTRACT Background:To analyze the use of antibiotics in the surgical ward of a tertiary university hospital through one day audit. Methods: Data were collected from the charts of hospitalized patients (pre-and postoperative) in a single, random visit in the surgical ward. Antibiotic prescription was classified as prophylactic, empirical, therapeutic intent with a known pathogen, therapeutic intent with an unknown pathogen or without rational basis, according to the preset criteria. Results: From 50 hospitalized patients, 46 were surgical (N=46). Antibiotics were prescribed to 13 subjects (28.3%). Drug association was used in seven patients (53.8%), and nineteen antibiotics were prescribed. Eight drugs (42.1%) were used as empirical or without rational basis, four in each group. Six drugs (31.6%) were used to treat infections with an unknown pathogen, three (15.7%) to treat infections with a know pathogen and two drugs (10.5%) for prophylactic use. Conclusion: Despite all concerns about the rational use of antimicrobials, in the studied population, almost half of the drugs were used without proper diagnosis or definite criterion. Antibiotic prescription is still a current problem. It must be faced with seriousness by surgeons, who must know when to indicate, how to indicate, and yet, when not to indicate.

473 Background: Cancer of the exocrine pancreas is a highly lethal malignancy. Based on a phase III study, FOLFIRINOX regimen became the standard first-line treatment for patients with good performance status. However, the optimal management strategy for patients who fail initial FOLFIRINOX remains undefined. We aim at reporting our experience with single-agent gemcitabine as a second-line treatment for advanced pancreatic cancer patients who progressed on FOLFIRINOX. Methods: Patients with advanced exocrine pancreatic adenocarcinoma who received gemcitabine (1.000 mg/m² on days 1, 8 and 15 every 4 weeks) until disease progression, as second-line therapy after FOLFIRINOX failure at our institution were retrospectively evaluated. Progression-free survival (PFS) and overall survival (OS) were estimated by the Kaplan-Meier method. Results: A total of 20 patients were reviewed. Most of them (60%) had metastatic disease while 40% had locally advanced tumors. Median age was 60 years (range 43–74) and 80% were male. Eastern Cooperative Oncology Group (ECOG) performance status was 0 or 1 in 65% and 2 or 3 in 35% of the patients. Median time on prior FOLFIRINOX therapy was 5 months. Median PFS and OS with gemcitabine were 2,0 (95% CI 1,2-2,8) and 5,7 months (95% CI 3,9-7,4), respectively. There were no deaths due to the treatment. Conclusions: In this study, gemcitabine was a reasonable second-line treatment option for patients with advanced pancreatic adenocarcinoma. Phase III trials are urgently needed exploring the role of gemcitabine in the second-line setting.

72 Background: A considerable number of patients with mGIC progress after exhausting all approved standard therapies but maintain an adequate performance status and could be candidates for further treatment. We aim at reviewing our experience with the use of a NGS platform in refractory mGIC and its clinical utility. Methods: We retrospectively reviewed demographics, NGS results, and the suggested therapies received by patients undergoing NGS (Foundation Medicine, Cambridge, MA, USA): exonic sequencing of 236 genes and selective intronic sequencing from 19 genes for refractory mGIC. Co-primary endpoints were the percentage of patients with targeted therapy options uncovered by mutational profiling and the percentage of them who received genotype-directed therapy. Results: Samples from 32 patients were tested. Primary tumors consisted of colorectal adenocarcinoma (37,5%), pancreatic adenocarcinoma (31,2%), gastric adenocarcinoma (12,5%), cholangiocarcinoma (12,5%) and hepatocellular carcinoma (6%). Most patients (87,5%) were found to harbor potentially actionable genetic alterations involving mitogen-activated protein kinase (93,7%), phosphatidylinositol 3-kinase-AKT (18,7%), p53 (50%) and cell-cycle regulation (9%) pathways. Of the 6 patients who received the suggested targeted therapy, 4 achieved an objective response. Conclusions: Mutational profiling using a targeted NGS panel identified potentially actionable alterations in the majority of advanced gastrointestinal cancer patients. The assay provided clinical benefit in 12% of the patients.