Oncological outcome after hyperthermic isolated limb perfusion for primarily unresectable versus locally recurrent soft tissue sarcoma of extremities

INTRODUCTION

The management of locally advanced extremity soft tissue sarcomas, particularly in terms of a limb salvage strategy, represents a challenge, especially in recurrent tumors. In the context of a patient-tailored multimodal therapy, hyperthermic isolated limb perfusion (ILP) is a promising limb-saving treatment option. We report the outcome of patients with primarily irresectable and locally recurrent soft tissue sarcoma (STS) treated by ILP.

PATIENTS AND METHODS

Data about patient demographics, clinical und histopathological characteristics, tumor response, morbidity and oncological outcome of all patients with STS, who underwent an ILP at our institution in a 10-year period, were retrospectively detected and analyzed.

RESULTS

The cohort comprised 30 patients. Two patients were treated with ILP for palliative tumor control, 13 patients because of a local recurrent soft tissue sarcoma (rSTS) and 15 patients because of primarily unresectable soft tissue sarcoma (puSTS). 25 of the 28 patients with curative intention received surgery after ILP (11 pts with rSTS and 14 pts with puSTS). Histopathologically we observed complete response in 6 patients (24%) and partial responses in 19 patients (76%) with a significant better remission in patients with puSTS (p = 0,043). Limb salvage rate was 75%. Mean follow-up was 69 months [range 13-142 months]. Seven (7/11; 64%) patients with rSTS and one (1/14; 7%) patient with puSTS developed local recurrence after ILP and surgery, whereas eight (8/13; 62%) rSTS patients and seven (7/15; 47%) puSTS patients developed distant metastasis. During follow-up, eight patients (28.5%) died of disease (5/13; 38%) rSTS and 3/15 (20%) puSTS. ILP in the group of previously irradiated sarcoma patients (n = 13) resulted in a limb salvage rate of 69% and was not associated in an increased risk for adverse events.

DISCUSSION

ILP for advanced extremity STS is a treatment option for both puSTS and rSTS resulting in good local control and should be considered in multimodal management. ILP is also a good option for patients after radiation history.

Prognostic subdivision of pT2 rectal carcinomas

PURPOSE

The aim of the present study is to explore the prognostic impact of a subdivision of pT2 by the depth of invasion into the muscularis propria in rectal carcinomas.

METHODS

Data from 269 consecutive patients with rectal carcinoma treated with primary tumor resection and lymph node dissection between 1986 and 2012 were analyzed with respect to locoregional and distant recurrence, disease-free survival, and overall survival. The depth of invasion into the muscularis propria of pT2 carcinomas was categorized by the pathologist into two groups: pT2a, invasion into the inner half of the muscularis propria; pT2b, invasion into the outer half of the muscularis propria.

RESULTS

One hundred nineteen of the 269 patients (44.2%) were classified pT2a and 150 patients (55.8%) were classified pT2b. In univariate analysis, significant differences between pT2a and pT2b carcinomas were found for locoregional recurrences (5-year rates 5.3 vs 14.0%; p = 0.025), distant metastases (14.1 vs 18.7%; p = 0.026), disease-free survival (78.2 vs 62.5%; p = 0.022), and overall survival (87.4 vs 72.5%; p = 0.013). In multivariate Cox regression analysis, the pT2 subdivision was found to be an independent risk factor for locoregional recurrence (hazard ratio 2.6; p = 0.023), disease-free survival (HR 1.4; p = 0.022), and overall survival (HR 1.5; p = 0.020), but only marginally for distant metastasis (HR 1.7; p = 0.083). Other independent prognostic factors were lymph node status, lymphatic invasion, and grading.

CONCLUSIONS

The depth of invasion into the muscularis propria is an independent prognostic factor for pT2 rectal carcinomas that will support decision-making for preoperative, surgical, and postoperative treatment.

Risk Factors for Regional and Systemic Metastases in Patients with Sentinel Lymph Node-negative Melanoma

BACKGROUND

Sentinel lymph node status is a strong prognostic factor in melanoma. However, up to 21% of sentinel lymph node-negative patients develop locoregional and distant metastases during follow-up.

AIM

To analyze risk factors for locoregional and distant metastasis in patients with sentinel lymph node-negative melanoma.

PATIENTS AND METHODS

A total of 545 patients underwent sentinel lymph node biopsy (SNB) between 2005 and 2013 at our hospital. Data for 449 patients with a negative SNB were analyzed regarding risk factors and development of metastases. Follow-up was performed until 2016.

RESULTS

A total of 72 SNB-negative patients developed metastases, including 25 (34.7%) distant and 47 (63.3%) locoregional metastases. Locoregional metastases occurred earlier compared to distant metastases (with a mean of 24.2 and 23.5 months for regional lymph node and cutaneous metastases, respectively, vs. 31.4 months for distant metastases). Patients with metastases despite negative SNB had a greater tumor thickness (p=0.001), a higher rate of nodular melanoma (p=0.001), ulceration (p<0.001), and were older (p=0.05) compared to SNB-negative patients without subsequent metastases. Out of SNB-negative patients, 16% developed metastases.

CONCLUSION

Close clinical follow-up including sonography of the draining lymph node region is mandatory for melanoma patients regardless of SNB status.

Survival analysis in rectal carcinoma after neoadjuvant chemoradiation: various methods with different results

PURPOSE

Survival is an important indicator of outcome quality in rectal carcinoma. The 5-year survival rate is the typical outcome measurement. In patients with neoadjuvant chemoradiation followed by curative surgery, 7 years of follow-up is recommended. Different methods of survival analysis lead to different results. Here, we compared four different methods.

METHODS

The data of 439 patients with rectal carcinoma treated with neoadjuvant chemoradiation followed by curative total mesorectal excision (TME) surgery between 1995 and 2010 were analysed. After stratifying by stage, relative survival (RS), cancer-related survival (CRS), overall survival (OS) and disease-free survival (DFS) were compared. In particular, the 3-year disease-free survival rate was compared to the 5- and 7-year overall survival rates.

RESULTS

In the total cohort, the 5-year survival rates ranged from 90% (RS), over 84% (CRS) and 83% (OS) to 72% (DFS). Depending on the stage of disease, the differences between the 5-year survival rates varied between 10 and 32 percentage points. The differences were lowest in UICC stage y0 and highest in UICC stage yIV. The 3-year DFS-rate was always lower (worse) than the 5-year OS rate and higher (better) than the 7-year OS rate, with the exception of stage yIV.

CONCLUSIONS

Comparisons of survival are only meaningful if the same methods are applied. The 3-year rate of DFS was always worse than the rate of 5-year OS. Therefore, the 3-year rate of DFS appears to be a useful surrogate indicator in rectal carcinoma treatment studies.

Prognosis of patients with colonic carcinoma before, during and after implementation of complete mesocolic excision

Background

The implementation of complete mesocolic excision (CME) for colonic cancer was accompanied by other important changes, including more patients with early diagnosis by screening and the introduction of adjuvant chemotherapy in patients with stage III disease. The contribution of CME remains unclear.

Methods

In this observational study, data from patients with stage I–III colonic carcinoma were analysed by comparing five time intervals: 1978–1984 (pre-CME), 1985–1994 (CME development), 1995–2002 (CME implementation), 2003–2009 (CME) and 2010–2014 (CME), with a special focus on indicators of process and outcome quality.

Results

During the observed periods, the median age of patients increased (from 65 to 67 years), there were more right-sided carcinomas (from 17·0 to 32·4 per cent), more stage I disease (from 14·0 to 27·7 per cent) and fewer patients with regional lymph node metastases (from 42·7 to 32·0 per cent). The proportion of patients with pN0 disease and at least 12 examined regional lymph nodes increased (from 84·8 to 100 per cent) as did the R0 resection rate (from 97·0 to 100 per cent). Overall morbidity increased, whereas the in-hospital mortality rate was stable (range 1·8–3·7 per cent). Use of adjuvant chemotherapy in stage III colonic carcinoma increased from 0 to 79 per cent. The improvement in outcome quality was more evident in stage III than in stage I–II tumours. In stage III, the 5-year locoregional recurrence rate decreased from 14·8 to 4·1 per cent (P = 0·046) and the 5-year cancer-related survival rate increased from 61·7 to 80·9 per cent (P = 0·010).

Conclusion

With CME, the quality indicators of process and outcome quality improved, especially in stage III colonic carcinoma. Adjuvant chemotherapy in stage III and multidisciplinary approaches in patients with metachronous distant metastases contributed to further outcome improvement.

Anti-TNF-refractory colitis after checkpoint inhibitor therapy: Possible role of CMV-mediated immunopathogenesis

Immune-related adverse events (irAEs) induced by checkpoint inhibitors are well known. Since fatal outcomes have been reported early detection and adequate management are crucial. In particular, colitis is frequently observed and can result in intestinal perforation. This is the first report of an autoimmune colitis that was treated according to algorithms but became resistant due to a CMV reactivation. The 32-y-old male patient with metastatic melanoma treated within an anti-PD-1/ipilimumab combination study developed severe immune-mediated colitis (CTCAE grade 3) with up to 18 watery stools per day starting 2 weeks after treatment initiation. After improving upon therapy with immunosuppressive treatment (high dose steroids and infliximab) combined with parenteral nutrition diarrhea again exacerbated. Additionally, the patient had asymptomatic grade 3 CTCAE amylase and lipase elevation. Colitis was monitored by weekly endoscopies and colon biopsies were analyzed histologically with CMV staining, multi-epitope ligand cartography (MELC) and qRT-PCR for inflammatory genes. In the course, CMV reactivation was detected in the colon and treated with antiviral medication in parallel to a reduction of corticosteroids. Subsequently, symptoms improved. The patient showed a complete response for 2 y now including regression of bone metastases. CMV reactivation under checkpoint inhibitor therapy in combination with immunosuppressive treatment for autoimmune side effects has to be considered in these patients and if present treated. Potentially, CMV reactivation is underdiagnosed. Treatment algorithms should include CMV diagnostics.

The impact of surgical quality on prognosis in patients undergoing rectal carcinoma surgery after preoperative chemoradiation

PURPOSE

The aim of the study was to analyse the impact of surgical quality on the prognosis of rectal carcinoma patients who underwent preoperative long-term chemoradiation and TME surgery.

METHODS

In a total of 314 patients, four quality indicators, including plane of surgery, pathological circumferential resection margin (pCRM), intraoperative local tumour cell dissemination and anastomotic leakage, were analysed with respect to locoregional recurrence, distant metastasis and overall survival.

RESULTS

In 260 (82.8 %) of the patients, all four quality indicators were fulfilled. In 30 (9.6 %) of the patients, at least one quality indicator was not fulfilled; in 24 (7.6 %) of the patients, the data were not complete. Locoregional recurrence was significantly increased in patients who underwent surgery in the muscularis propria plane, who had a pCRM ≤ 1 mm or who experienced local tumour cell dissemination. In patients who had at least one quality indicator that was not fulfilled (suboptimal surgical quality), the 5-year rate of locoregional recurrence in those patients was 23.1 % compared to 4.8 % in patients who underwent optimal surgery (P = 0.001). In multivariate analysis, suboptimal surgery (hazard ratio (HR) 3.9; P = 0.020), abdominoperineal excision (HR 4.7; P = 0.003) and poor regression of primary tumours (HR 8.5; P < 0.001) were identified as independent prognostic factors for locoregional recurrence. In contrast to type of surgical treatment, ypT, ypN and regression grade, the quality of surgery did not significantly influence distant metastasis or overall survival.

CONCLUSIONS

Even after preoperative chemoradiation, the surgical quality still has a strong impact on local control in patients with rectal carcinoma.

A hundred patients with vertical rectus abdominis myocutaneous (VRAM) flap for pelvic reconstruction after total pelvic exenteration

PURPOSE

We analysed the outcomes of a series of 100 consecutive patients with anorectal cancer with neoadjuvant radiochemotherapy and abdominoperineal exstirpation or total pelvic exenteration, who received a transpelvic vertical rectus abdominis myocutaneous (VRAM) flap for pelvic, vaginal and/or perineal reconstruction and compare a cohort to patients without VRAM flaps.

METHODS

Within a 10-year period (2003-2013) in our institution 924 patients with rectal cancer stage y0 to y IV were surgically treated. Data of those 100 consecutive patients who received a transpelvic VRAM flap were collected and compared to patients without flaps.

RESULTS

In 100 consecutive patients with transpelvic VRAM flaps, major donor site complications occurred in 6 %, VRAM-specific perineal wound complications were observed in 11 % of the patients and overall 30-day mortality was 2 %.

CONCLUSIONS

The VRAM flap is a reliable and safe method for pelvic reconstruction in patients with advanced disease requiring pelvic exenteration and irradiation, with a relatively low rate of donor and recipient site complications. In this first study, to compare a large number of patients with VRAM flap reconstruction to patients without pelvic VRAM flap reconstruction, a clear advantage of simultaneous pelvic reconstruction is demonstrated.

Prognostic subdivision of ypT3 rectal tumours according to extension beyond the muscularis propria

Background

The subdivision of T3 in rectal carcinoma according to the depth of invasion into perirectal fat has been recommended in the TNM Supplement since 1993. This study assessed the prognostic impact of this pathological staging in tumours removed after neoadjuvant chemoradiotherapy (ypT3).

Methods

Data from patients with ypT3 rectal carcinoma (less than 12 cm from the anal verge) treated with neoadjuvant chemoradiation and total mesorectal excision were analysed. Tumour category ypT3 was subdivided into ypT3a (5 mm or less) and ypT3b (more than 5 mm), based on histological measurements of maximal tumour invasion beyond the outer border of the muscularis propria.

Results

Important differences between ypT3a (81 patients) and ypT3b (43) were found in 5-year rates of locoregional recurrence (7 versus 18 per cent; P = 0·049), distant metastasis (20 versus 41 per cent; P = 0·002), disease-free survival (73 versus 47 per cent; P = 0·001), overall survival (79 versus 74 per cent; P = 0·036) and cancer-related survival (81 versus 74 per cent; P = 0·007). In Cox regression analyses, the ypT3 subclassification was identified as an independent prognostic factor for disease-free (ypT3b: hazard ratio (HR) 2·13, 95 per cent confidence interval 1·16 to 3·89; P = 0·014), observed (ypT3b: HR 2·02, 1·05 to 3·87; P = 0·035) and cancer-related (ypT3b: HR 2·46, 1·20 to 5·04; P = 0·014) survival. Extramural venous invasion was found to be an additional prognostic factor, but the pathological node category after chemoradiotherapy (ypN) did not influence survival.

Conclusion

In ypT3 rectal carcinomas, the proposed subclassification is superior to ypN in predicting prognosis.

Assessment of advances of outcome quality in colon carcinoma at a single center

SUMMARY Background: Measuring outcome quality in colon carcinoma is important for efficient quality management. Patients & methods: Four complementary methods of survival analysis have been applied to compare the survival of patients with curatively resected colon carcinoma in two time periods: 1978–1994 (n = 979) and 1995–2005 (n = 639). Results: The 5-year survival rates of both cohorts varied widely depending on the applied analysis method with various improvements in the survival rates. The most evident progress was found in cancer-related survival of pathological stage III and IV disease. Conclusion: High-quality, complete follow-up data facilitate a complex analysis of survival. Advances in surgical technique and treatment of distant metastases, both in a multidisciplinary setting when appropriate, may be important reasons for improved survival in colon carcinoma.

[Principles and technique of lymph node dissection in colorectal carcinoma]

Colorectal carcinoma is a common malignant tumor which shows a standard behavior for lymphogenic metastasis. Depending on the localization of the primary tumor the corresponding lymphatic area also has to be removed because lymph node metastases can already be present by every tumor even if there is no obvious intraoperative evidence. Lymphatic drainage is essentially oriented to the supplying arteries of the corresponding intestinal segment. The anatomy of arterial supply is individually variable and often deviates from the usual textbook presentation. In this review the oncological requirements of an adequate lymph node dissection in colorectal carcinoma are described with emphasis on the technical aspects to obtain an optimal specimen.

[Palliative treatment of metastases in malignant melanoma]

Due to the broad variation of clinical presentation in metastasised malignant melanoma, a careful staging and individual treatment of these patients is required. Especially, the occurrence of locoregional or / and distant metastasis presents an important problem. Not only treatment with a curative intent but also sophisticated surgical procedures with a palliative intent are necessary in patients with tumour complications. These procedures do not improve the oncological prognosis. However, they may rescue patients from life-threatening situations. Therefore, palliative surgery of metastases plays an important role and requires assessment by an experienced oncological team.

[Neoadjuvant radiochemotherapy for rectal cancer]

Neoadjuvant radiochemotherapy has become established treatment for rectal cancer. It is indicated when primary R0 resection is not an option, in cases of higher risk of locoregional relapse following surgical treatment alone, and when initially impossible conservation of the anal sphincter becomes possible in conjunction with neoadjuvant radiochemotherapy. The indication for radiochemotherapy in the upper third of the rectum is still controversial. Reevaluation of the tumor situation following neoadjuvant treatment is necessary before decisions on operative strategy. Modern imaging techniques are limited in this respect, as they hardly allow differentiation between living tumor tissue and lesions. In case of doubt clarity is possible only through surgical exploration, taking R1 resection into account. Overall the recognition of lymph node metastasis is not a sufficient indicator of local relapse. The frequency of postoperative complications following neoadjuvant radiochemotherapy is independent of the operative method. The effect of neoadjuvant radiochemotherapy on long-term survival and formation of distant metastases is still not clarified. Current studies seek clarification through the use of new chemotherapies and modified treatment regimes. Further, the correct time interval between the end of neoadjuvant radiochemotherapy and the following surgical therapy has yet to be determined. This applies also to the management of patients following complete remission.

Lymph node dissection in rectal carcinoma: TME and what else?

Total mesorectal excision (TME) has been established as a standardized radical surgical procedure in malignant tumors of the middle and lower rectal third. In carcinomas of the upper rectal third, TME is seen as controversial. The aims of TME are low rates of locoregional recurrences and good functional results. Total mesorectal excision in the radical surgical treatment of lower and middle third rectal carcinomas is the essential part of lymphatic dissection in these tumors. It will be discussed if additional procedures are relevant for lymph node dissection, and how far they are established and approved. As yet, the results of laparoscopic TME show no advantage over conventional TME. The quality of TME should be assessed by a pathologist according to predefined criteria. In multimodal treatment regimens, TME is also essential.

Surgical management of pulmonary metastases from colorectal cancer in 153 patients

BACKGROUND

Surgery has become a recognized therapeutic means in selected patients with pulmonary metastases from colorectal origin. We reviewed our experience in the surgical treatment of 153 patients with pulmonary colorectal metastases and investigated factors affecting survival.

METHODS

A retrospective analysis of the records of all patients (n = 153) with pulmonary metastases from colorectal cancer who underwent thoracotomy between 1978 and 2003 at a single surgical center was performed.

RESULTS

One hundred fifty-three patients with pulmonary metastases from colon (n = 61) or rectal (n = 92) cancer underwent 180 thoracotomies. The 2- and 5-year probabilities of survival after the first thoracotomy were 64% and 37%, respectively. Sex, age, site, International Union Against Cancer stage of the primary tumor, prethoracotomy carcinoembryonic antigen level, size of metastases, and previous resection of hepatic metastases were not found to be statistically significant prognostic factors. Number of metastases (solitary vs. multiple), mode of operation (wedge vs. anatomical resection), disease-free interval (DFI; > 36 months), negative hilar or mediastinal lymph node status, resection margin > 10 mm, and administration of intraoperative blood substitution were predictors of a longer survival duration by univariate analysis, but only number of metastases (P = .019), mode of operation (P = .004), DFI (P = .027), and intraoperative blood substitution (P = .002) were identified as independent prognostic factors by multivariate analysis.

CONCLUSIONS

Pulmonary resection for metastases from colorectal cancer is safe and results in long-term survival in selected patients. Single metastases, anatomical resection, intraoperative blood substitution, and DFI > 36 months seem to be the most reliable predictors of survival.

The influence of abdomino-peranal (intersphincteric) resection of lower third rectal carcinoma on the rates of sphincter preservation and locoregional recurrence

OBJECTIVE

The most extended form of rectal resection, representing the very last option for sphincter preservation is abdomino-peranal intersphincteric resection for tumours of the lower third which otherwise would not be resectable with preservation of the sphincter by an abdominal approach alone.

PATIENTS AND METHODS

The data of 476 patients with a carcinoma in the lower third of the rectum who underwent primary treatment for stage I-III disease by low anterior resection, abdomino-peranal (intersphincteric) resection or abdominoperineal excision between 1985 and 2001 were analysed. The time periods 1985-94 and 1995-2001 were compared.

RESULTS

The rate of intersphincteric resections increased from 3% in 1985-94 to 27% in 1995-2001 while abdominoperineal excisions decreased. Postoperative complication rate was not increased in intersphincteric resections (25%) while postoperative mortality did not differ between the operative procedures. The overall 5-year-rate of locoregional recurrence decreased from 18% to 16%. In intersphincteric resections 14.2% of the patients treated with radiochemotherapy developed locoregional recurrence, while this rate was 46.5% (7/18) if adjuvant treatment was not administered (P = 0.0200). The cancer-related 5-year survival rate was not altered by intersphincteric resection.

CONCLUSION

In carcinomas of the lower third of the rectum, the application of abdomino-peranal intersphincteric resection can reduce the need for rectal excision by 20%. Neo-/adjuvant radiochemotherapy is required to reduce locoregional recurrence to an acceptable level.

Reduction in adhesive small-bowel obstruction by Seprafilm adhesion barrier after intestinal resection

INTRODUCTION

Although Seprafilm has been demonstrated to reduce adhesion formation, it is not known whether its usage would translate into a reduction in adhesive small-bowel obstruction.

METHODS

This was a prospective, randomized, multicenter, multinational, single-blind, controlled study. This report focuses on those patients who underwent intestinal resection (n = 1,701). Before closure of the abdomen, patients were randomized to receive Seprafilm or no treatment. Seprafilm was applied to adhesiogenic tissues throughout the abdomen. The incidence and type of bowel obstruction was compared between the two groups. Time to first adhesive small-bowel obstruction was compared during the course of the study by using survival analysis methods. The mean follow-up time for the occurrence of adhesive small-bowel obstruction was 3.5 years.

RESULTS

There was no difference between the treatment and control group in overall rate of bowel obstruction. The incidence of adhesive small-bowel obstruction requiring reoperation was significantly lower for Seprafilm patients compared with no-treatment patients: 1.8 vs. 3.4 percent (P < 0.05). This finding represents an absolute reduction in adhesive small-bowel obstruction requiring reoperation of 1.6 percent and a relative reduction of 47 percent. In addition, a stepwise multivariate analysis indicated that the use of Seprafilm was the only predictive factor for reducing adhesive small-bowel obstruction requiring reoperation. In both groups, 50 percent of first adhesive small-bowel obstruction episodes occurred within 6 months after the initial surgery with nearly 30 percent occurring within the first 30 days. Additionally no first adhesive small-bowel obstruction events were reported in Years 4 and 5 of follow-up.

CONCLUSIONS

The overall bowel obstruction rate was unchanged; however, adhesive small-bowel obstruction requiring reoperation was significantly reduced by the use of Seprafilm, which was the only factor that predicted this outcome.

Laparoscopic TME-the surgeon's or the patient's preference

Since laparoscopic surgery in rectal cancer was introduced ten years ago large patient collectives have been published by several authors in the meantime. The literature was carefully reviewed to analyse data on postoperative complications, long term prognosis and quality of life after laparoscopic surgery for rectal cancer to answer the question whether laparoscopic surgery is still just feasible or maybe has even reached the golden standard. The review showed that there is not a single prospectively randomized trial published comparing laparoscopic vs. open surgery for rectal cancer. It is clearly evident that until now the most laparoscopic series are published with patients selected according to criteria that vary significantly especially regarding the kind of procedures performed (anterior, low anterior, intersphincteric resections and abdomino-perineal excision), other demographic items like gender, body mass index, eventual prior laparotomies, emergencies and tumor related characteristics like tumor stage or T-categories. At the moment any data concerning outcome from prospectively randomized trials comparing laparoscopic versus open surgery for rectal cancer are missing. Therefore, there is more speculation and belief concerning the true quality of laparoscopic surgery. The review in the literature only indicates, that laparoscopic surgery for rectal cancer is feasible. To prove the potential advantage of laparoscopic surgery in rectal cancer randomized trials are essential. If a surgeon discusses laparoscopic surgery outside a randomized trial, he should go through a questionnaire, presented in the paper which reflects the present situation without any proven advantage and not available long term results and should leave a final decision to the patient.

Functional outcome after intersphincteric resection of the rectum with coloanal anastomosis in low rectal cancer

OBJECTIVES

Anterior rectal resection with partial removal of the internal sphincter is an option for low rectal cancer. The objective of this study was to evaluate the functional outcome after this intersphincteric rectal resection.

METHODS

Anal continence was evaluated by anorectal manometry and a standardized questionnaire (Wexner Score) in 33 patients 28+/-15 weeks and 100+/-45 weeks, respectively, after intersphincteric resection. Nineteen of the 33 patients were reconstructed with a straight anastomosis; 12 received a colonic J-pouch.

RESULTS

Post-operatively, 25.8% of the patients were incontinent to solid stool and 54.8% were incontinent to liquid stool at least once a week. Mean and maximum resting tone (24+/-10 and 40+/-13 mmHg), maximum tolerable volume (77+/-28 ml) and rectal compliance (1.4+/-1.2 ml/mmHg) were reduced in anorectal manometry. Squeeze pressures remained unchanged. Only the maximum tolerable volume correlated significantly with the continence score (r=-0.45, p<0.05). The Wexner score and maximum tolerable volume were significantly better after colonic J-pouch reconstruction than after straight anastomosis (9.9+/-4.5 vs 13.4+/-4.0, p<0.05, 65+/-20 ml vs 100+/-27 ml, p<0.01).

CONCLUSION

Intersphincteric resection of the rectum leads to impaired post-operative continence. The functional outcome is improved with a colonic J-pouch.

[Interdisciplinary aspects of surgery of the pelvis minor and retroperitoneum]

Surgery of diseases of the pelvis minor and retroperitoneum such as inflammatory disease, malignant tumours, or trauma of pelvic organs need the close interdisciplinary collaboration of visceral surgeons, gynaecologists, and urologists. This collaboration begins in planning diagnostic and therapeutic procedures. It has to be clear who performs which operative step and when. Excellent long-term results in malignant disease show that the greater effort is worthwhile. The rate of postoperative morbidity after these multivisceral resections is high also in specialised centers, but mortality is below 5%. Because of the growing number of long-term survivors, preservation of quality of life becomes more and more important.

Palliative second-line treatment with weekly high-dose 5-fluorouracil as 24-hour infusion and folinic acid (AIO) plus oxaliplatin after pre-treatment with the AIO-regimen in colorectal cancer (CRC)

BACKGROUND AND AIMS

The aim of this work was to evaluate the efficacy and safety of second-line treatment with weekly high-dose 5-Fluorouracil (5-FU) as a 24-hour infusion (24-h inf.) and folinic acid (FA) (AIO-regimen) plus Oxaliplatin (L-OHP) after pre-treatment with the AIO regimen, focusing in particular on the efficacy of palliative first- and second-line treatment in colorectal carcinoma (CRC).

PATIENTS AND METHODS

Patients with non-resectable distant CRC metastases were enrolled in a prospective phase II study for palliative second-line treatment after previous palliative first-line treatment in accordance with the AIO regimen. On an outpatient basis, the patients received a treatment regimen comprising biweekly 85 mg/m2 L-OHP in the form of a 2-hour intravenous (i.v.) infusion and 500 mg/m2 FA as a 1 to 2-hour i.v. infusion, followed by 2,600 mg/m2 5-FU administered as a 24-h inf. i.v. once weekly. A single treatment cycle comprised 6 weekly infusions followed by 2 weeks of rest.

RESULTS

During second-line treatment, a total of 26 patients received 340 chemotherapy applications. As the main symptom of toxicity, diarrhoea (NCI-CTC toxicity grade 3+4) presented in 5 patients (19%; 95% CI: 4-34), followed by nausea (CTC grade 3) in one patient (4%; 95% CI: 0-11). Twenty-three patients were evaluable for treatment response. The remission data can be summarised as follows: Complete remission (CR): n=1 (4%; 95% CI: 0-13); partial remission (PR): n=3 (13%; 95% CI: 0-27); stable disease (SD): n=11 (48%; 95% CI: 27-68) and progressive disease (PD): n=8 (35%; 95% CI: 15-54). The median progression-free survival (PFS) rate (n=26) was 3.3 months (range 0-11.5), the median survival time counted from the start of second-line treatment (n=26) 11.6 months (range 2.1-33.0) and the median survival time counted from the start of first-line treatment (n=26) 19.9 months (range 7.7-49.8).

CONCLUSION

Palliative second-line treatment according to the AIO regimen plus L-OHP is feasible in an outpatient setting and well tolerated by the patients. Tumour control (CR + PR + SD) was achieved in 65% of the patients, the median survival time being 11.6 months. The AIO regimen followed by the 'AIO regimen plus L-OHP' therapy sequence led to a promising median survival time of 19.9 months (range 7.7-49.8).

Can neoadjuvant radiochemotherapy improve the results of multivisceral resections in advanced rectal carcinoma (cT4a)

OBJECTIVE

To investigate the influence of neoadjuvant radiochemotherapy (nRCT) in advanced rectal carcinoma (cT4a), the prospectively collected data of all patients treated by extended multivisceral resections during the last 16 years were analysed.

METHODS

Between 1985 and 2000, 113 patients with clinical T4a rectal carcinoma (invasion of adjacent organs or structures), were treated by extended multivisceral surgery. In 1995 nRCT was introduced as a standardized treatment modality in cT4a carcinomas and applied in 32 patients. Six weeks after completion of nRCT, resection was performed. In all patients at least one additional organ was removed because of clinically evident tumour infiltration. In one third of patients (36/113) more than one organ had to be removed.

RESULTS

The rate of curative (R0) resections was 89% (101/113). It was similar in patients with and without nRCT (91 vs. 89%). In 40 (35%) patients histopathological examination could verify tumour invasion in adjacent organs (34% with vs. 36% without nRCT). The 3-year rate of locoregional recurrence after R0-resection was 12.7%. In multivariate Cox regression analysis the regional lymph node status was the most important prognostic factor (relative risk 5.8, P = 0.007). Neoadjuvant or adjuvant treatment reduced the risk by factor 0.4 (P = 0.211). The 3-year cancer-related survival rate of all patients with curative resection was 72.9%. It was 89.4% in the series treated with nRCT, while it was only 66.7% in patients with neither neoadjuvant nor adjuvant therapy. The relative risk for patients with lymph node metastases was 7.0 (P < 0.001) while it was only 0.2 in patients treated with nRCT (P = 0.049).

CONCLUSIONS

Together with curative extended multivisceral resection nRCT can improve prognosis in patients with advanced rectal carcinoma (cT4a).

[Angiomyolipoma of the colon - case report and review of the literature]

Angiomyolipoma is one of the benign hamartomas that is found sporadically or associated with tuberous sclerosis. It is a rare soft tissue tumor involving mostly the kidneys, sometimes other visceral organs. The tumor is composed of smooth muscle cells, adipocytes and small sized hyalinized vessels. We present the case of a 74-year-old man with a bifocal angiomyolipoma of the colon. This diagnosis was confirmed at surgery, where a partial colectomy was performed. Histologic examination disclosed the tumor. The patient had no signs of family history of tuberous sclerosis. Extrarenal angiomyolipoma is rare and this may be the first report of bifocal colonic angiomyolipoma.

[Changes and complication rate in surgery for thoracic esophageal carcinoma]

AIM

In an analysis over 22 years it was investigated which parameters have changed in the operative treatment of thoracic esophageal carcinoma over time and in how far they have influenced complication rate.

PATIENTS AND METHODS

Between 1978 and 1999 386 patients (350 men, 36 women) underwent resection for thoracic esophageal carcinoma (squamous cell carcinoma n=300, adenocarcinoma n=86). Cervical tumors were excluded from analysis. The time periods from 1978 to 1988 (n=242) and from 1989 to 1999 (n=144) were separately analyzed and compared with respect to age, sex, histological type, main tumor location, neoadjuvant therapy, method of operation, esophageal substitute and positioning of the substitute, R-status, pT/pN classification, UICC stage, number of dissected lymph nodes, complication rate, postoperative mortality and survival.

RESULTS

Comparison of the two time periods showed a significant increase in adenocarcinomas and main tumor location in the lower thoracic third of the esophagus. Furthermore, significant changes concerning the indication of neoadjuvant chemoradiation, operative approach, esophageal substitute, R-status and number of dissected lymph nodes were observed. Tumor stage (pT/pN classification and UICC stage) significantly shifted towards earlier stages. Total complication rate dropped tendentially form 68.5 % to 59.0 % (p=0.061). Hospital mortality was significantly reduced from 24 % to 12.5 %, whereas anastomotic leakages and multiorgan failure remained on a constant level. Median survival of R0 resected patients was significantly prolonged from 19 months to 34 months.

CONCLUSIONS

The increase of esophageal adenocarcinoma, a more strict patient selection (staging, functional status), standardization of operative technique as well as an optimized intensive care management are among the important changes in the operative management of thoracic esophageal carcinoma that have resulted in an improvement of prognosis of curatively resected patients. In spite of a more aggressive operative approach, i. e. lymph node dissection, operative mortality could be reduced by nearly 50 % in the face of a tendentially declining total complication rate.

Late locoregional recurrence in rectal carcinoma

AIMS

Locoregional recurrence in rectal carcinoma usually occurs within the first five years of treatment. In recent years we have increasingly diagnosed patients with late locoregional recurrence more than 5 years after primary treatment.

METHODS

The data of 978 patients with invasive stage I-III rectal carcinoma who underwent curative resection (R0) between 1978 and 1990 were analysed retrospectively. The median follow-up time was 10 years.

RESULTS

The earliest locoregional recurrence was observed at 2 months, the latest at 148 months (extramural locoregional recurrence) after primary treatment. Within 1, 2 and 5 years 34, 64 and 91 per cent of all locoregional recurrences had been diagnosed. The 2-, 5- and 10-year locoregional recurrence rates of all patients increased from 11.3 to 16.7 to 18.8 per cent. The time lapse to diagnosis of locoregional recurrence was significantly influenced by the pN category (pN0: later), grading (low grade: later) and tumour cell dissemination (present: earlier). Locoregional recurrence was also diagnosed significantly earlier in patients undergoing regular follow-up. The curative reoperation rate was 22 per cent (n=37), being higher in patients with intramural locoregional recurrence (49 per cent), after primary anterior resection (32 per cent) and in the absence of distant metastases (29 per cent).

CONCLUSION

Long-term follow-up beyond five years demonstrates increasing numbers of late locoregional recurrences.

Lymph node dissection for clinically evident lymph node metastases of malignant melanoma

AIMS

A considerable number of melanoma patients present with clinically evident regional lymph node metastases. Factors influencing prognosis following therapeutic lymph node dissection (TLND) were evaluated.

METHODS

In total 140 patients (68 women, 72 men, median age 53 years) with established regional lymph node metastases, but without clinically detectable distant metastases, received cervical, axillary or ilioinguinal TLND between 1978 and 1997 and were retrospectively reviewed. Uni- and multivariate survival analysis was performed.

RESULTS

Median survival for all 140 patients was 25 months; the observed overall 5 year survival rate was 30%. Age greater than 50 years, primary tumour site on the trunk, more than three lymph node metastases and extracapsular spread were associated with a poor prognosis. In multivariate analysis age (< or =50 years vs >50 years, P=0.02), location of the primary tumour (non-truncal vs truncal, P=0.005), number of lymph nodes involved ( n< or =3 vsn >3, P=0.01) and extracapsular spread (none vs present, P=0.04) proved to be independent prognostic factors.

CONCLUSIONS

TLND is worthwhile and offers a potential chance of cure in about one-third of melanoma patients with established regional lymph node metastases. There are subgroups with a particularly poor prognosis in whom the benefit of radical surgery alone is limited.

[Regional chemotherapy--perfusion of the extremities]

Hyperthermic isolated limb perfusion with cytostatic drugs (HILP) is indicated in locoregional recurrences of malignant melanoma of the limbs. As a neoadjuvant treatment it is also used for non-curatively resectable soft tissue sarcoma or their recurrences on the extremities. Up to now, melphalan is still the standard drug in HILP for malignant melanoma. With melphalan, complete response can be achieved in 65-80% for clinically detectable in transit metastases (+/- regional lymph node metastases). The combination of tumor necrosis factor (TNF) alpha with melphalan has considerably improved response rates of HILP in sarcoma. In more than 80% of the patients the otherwise necessary amputation of the limb can be avoided. The combination of TNF with other drugs than melphalan could possibly further improve results of HILP in sarcoma patients. The high rate of local recurrences of malignant melanoma after HILP poses an unsolved problem yet.

Testing a new staging system for cutaneous melanoma proposed by the American Joint Committee on Cancer

The American Joint Committee on Cancer (AJCC) recently proposed a new staging system for cutaneous melanoma. We tested its practicability and its prognostic value was compared with the currently used TNM classification. The data of 1976 melanoma patients were used for the testing. 1218 patients (61.6%) could be assigned to the proposed pT classification, 136 patients (90.1%) with lymph node metastases and/or in-transit metastases to the proposed pN classification and all 14 patients with distant metastases to the proposed pM classification. Proposed pathological staging was possible for 971 patients (49%). The number of pT1 patients (399 versus 230) and stage I patients (544 versus 393) was distinctly higher in the proposed classification. In proposed stage II and III groups, subgroups with different prognosis could be identified. The new staging system includes more detailed information on clinical and pathohistological findings. Nevertheless, it is practicable and enables more patients with excellent prognosis to be identified.

Low bone mineral density after total gastrectomy in males: a preliminary report emphasizing the possible significance of urinary net acid excretion, serum gastrin and phosphorus

The bone mineral density (BMD) and the associated extracellular status of mineral and acid-base metabolism were evaluated in 11 males, 3-18 years after total gastrectomy (GX). In the lumbar spine, but not in the femoral neck, BMD was decreased in seven, normal in three, and falsely high in one individual. Relative to the limits of normalcy, fasting serum levels of gastrin were low, but normal for calcium, phosphorus, parathyroid hormone, calcitonin and vitamin D, while the level of total alkaline phosphatase was elevated; fasting urine pH and calcium were low, while phosphorus and net acid were high. Regression analyses revealed serum gastrin and phosphorus, and urinary net acid as possible predictors of BMD. It was concluded that over the long-term GX evokes low BMD, but not hyperparathyroidism and deranged vitamin D metabolites. Future studies may focus on gastrin, parathyroid hormone-independent hyperphosphaturia and disturbed acid-base metabolism as indicators of a new extra-cellular equilibrium of minerals.

[Intraabdominal abscesses. Intervention versus surgical treatment]

As the diagnosis of intraabdominal abscesses has been continuously facilitated by the use of ultrasound and CT-scan, interventional management by percutaneous drainage provides an excellent alternative treatment concept to conventional open surgery. With the use of special flow-suction-catheters which are placed into the abdomen under sonographic or computertomographic guidance, the success rates in the literature are ranging between 33% and 100%, depending on the initial situation, etiology and morphology of the findings. Studies performed with comparable patient collectives showed that interventional treatment methods had equal results to conventional surgery. Under favorable conditions such as in lesions situated in the periphery of the abdomen, with uncomplicated access ways through the abdominal wall and with an etiology of postoperative complications without a primary intraabdominal disease, with homogenous fluid collections in undivided or communicating spaces, the success rates can be raised to above 80%. A close cooperation between radiologists and surgeons in indication, conduct and course of treatment is indispensible for a successful application of these well tolerable interventional treatment concepts.

[Does sentinel node biopsy (SNB) solve the problem of elective lymph node excision in malignant melanoma?]

Elective lymph node dissection in high-risk melanoma has been hotly debated for years. The technique of sentinel node (SN) biopsy may be a solution to the problem. Consequently, radical lymph node dissection is restricted to patients with an actual metastatic involvement of the SN (20-25%). The use of a hand-held gamma probe increases accuracy of SN detection.

[Malignant melanoma of the skin: is there a curative surgical approach in locoregional metastasis?]

Between 1969 and 1993 at the Surgical University Hospital of Erlangen, 273 patients with synchronous or metachronous locoregional metastases were operated on with curative intent; patients with distant metastases at the time of primary operation or first recurrency were excluded. In 216 patients (79.1%) a curative operation was performed and we achieved a statistically significant improvement of the 5-year-survival rate compared with those patients treated only palliatively (39.3% vs. 21.1%, p < 0.01). If regional lymph node metastases occur, the prognosis becomes significantly worse (5-year survival rate 45.2% vs. 25.2%, p < 0.01); hyperthermic isolated limb perfusion shows a high importance in the treatment of locoregional metastases and the 5-year survival rate of patients treated with hyperthermic limb perfusion is significantly higher (39.0 vs. 64.2%, p < 0.05).

[Locoregional recurrence of melanomas of the extremities after hyperthermic extremity perfusion: is reperfusion of value?]

Isolated limb reperfusion in patients with locoregional recurrence after previous isolated limb perfusion achieves local tumor control in a high percentage of cases. One of the main aims of the repeat procedure is limb salvage, which was possible in 96% of our patients. Complication rate of reperfusion is acceptably low.

Mesorectal lymph node dissection: is it beneficial?

Locoregional recurrences and distant metastases are the determinants of the long-term prognosis following curative resection of rectal carcinoma. While distant metastases cannot be affected by the surgical treatment of the primary tumor, avoidance of local recurrence by the surgeon is of special significance as the predominant prognostic factor. Analysis of the long-term results achieved by various surgeons led to the concept of mesorectal excision - the removal of the rectum together with all additional tissue invested by the adjacent visceral fascia, that is, fatty tissue, lymph nodes, and lymphatic vessels, by sharp dissection of the appropriate anatomical plane. In our own patient material the 5-year survival rate following R0 resection was 85% for all stages, provided no local recurrence developed. This contrasts with a figure of only 23% in those who did develop local recurrence. The local recurrence rate decreased from 39.4%, with a 50% 5-year survival rate in 1974, to 9.8% and a 71% survival rate in 1991, although the rate of distant metastases remained constant. Among the patients treated between 1988 and 1994 the local recurrence rate was determined by depth of infiltration (1987 UICC classification: pT1 0%, pT2 10%, pT3 14%, pT4 28%), extent of lymph node infiltration (pN0 6%, pN1 15%, pN2 26%, pN3 25%), grading (G1 9%, G2 12%, G3 21%), and location within the rectum (upper third 13%, middle third 8%, lower third 17%), with combinations of unfavorable initial factors leading to higher local recurrence rates. The elevated local recurrence rates seen in the 1970s, in particular in the case of tumors of the lower third, were traced retrospectively to incomplete mesorectal excision, the implementation of which reduced the local recurrence rate initially to less than 10%, and then to the current 4.1%. From the oncological point of view, mesorectal excision must be considered to confer considerable benefit. In the case of carcinomas of the upper third of the rectum, mesorectal resection carried out to just 5 cm below the lower tumor edge is sufficient, however, without coning, while deeper carcinomas mandate total mesorectal excision.

Prophylactic isolated limb perfusion for localized, high-risk limb melanoma: results of a multicenter randomized phase III trial. European Organization for Research and Treatment of Cancer Malignant Melanoma Cooperative Group Protocol 18832, the World Health Organization Melanoma Program Trial 15, and the North American Perfusion Group Southwest Oncology Group-8593

PURPOSE

Patients with primary cutaneous melanoma > or = 1.5 mm in thickness are at high risk of having regional micrometastases at the time of initial surgical treatment. A phase III international study was designed to evaluate whether prophylactic isolated limb perfusion (ILP) could prevent regional recurrence and influence survival.

PATIENTS AND METHODS

A total of 832 assessable patients from 16 centers entered the study; 412 were randomized to wide excision (WE) only and 420 to WE plus ILP with melphalan and mild hyperthermia. Median age was 50 years, 68% of patients were female, 79% of melanomas were located on a lower limb, and 47% had a thickness > or = 3 mm.

RESULTS

Median follow-up duration is 6.4 years. There was a trend for a longer disease-free interval (DFI) after ILP. The difference was significant for patients who did not undergo elective lymph node dissection (ELND). The impact of ILP was clearly on the occurrence-as first site of progression - of in-transit metastases (ITM), which were reduced from 6.6% to 3.3%, and of regional lymph node (RLN) metastases, with a reduction from 16.7% to 12.6%. There was no benefit from ILP in terms of time to distant metastasis or survival. Side effects were higher after ILP, but transient in most patients. There were two amputations for limb toxicity after ILP.

CONCLUSION

Prophylactic ILP with melphalan cannot be recommended as an adjunct to standard surgery in high-risk primary limb melanoma.

[Electronic data processing in ward management--possibilities for rationalization and cost control]

Electronic data processing in ward management increases cost and time efficiency. Nurses and doctors will have more time to concentrate their genuine rather than administrative duties. Therefore the presented model has gained high acceptance.

[Lymph node dissections in malignant melanoma]

Elective lymph node dissection and its potential as a staging procedure, the prognosis of established lymph node metastases and the sentinel lymph node identification procedure are the most important aspects of lymph node dissection in malignant melanoma. It is widely accepted that subgroups of patients benefit from elective lymph node dissection. The question of which parameters identify the relevant patients properly is still under discussion. pT-categories are the most important prognostic factor; however, localisation and type of tumour and the sex of the patients are additional parameters influencing patient selection. Recently, the first studies have identified subgroups of nodal positive patients who would profit from adjuvant chemo-/immunotherapy. Therefore, lymph node dissection as a staging procedure has to be discussed in the future. Identification of the sentinel lymph node is receiving increasing attention because of its potential influence on the reassessment of elective lymph node dissection. However, this method needs further evaluation. If lymph node metastases have occurred, the prognosis of malignant melanoma decreases by 20%-50%, depending on the extent of metastasis in the individual case. The relevant topics and results are discussed on the basis of data of the Surgical Department of the University Hospital of Erlangen-Nuremberg.

[Is surgical therapy of distant metastases of malignant melanoma worthwhile?]

Distant metastases of malignant melanoma are generally considered as incurable related with an unfavourable prognosis. On the basis of our retrospective analysis of surgical treatment, subgroups of patients could be identified showing a significant improvement in survival after complete surgical removal of metastases. In single cases, survival longer than 10 years was observed. The surgical therapy of distant metastases of malignant melanoma is based on a strict patient selection and is only advantageous to those patients whose tumor tissue can be removed completely.

[Prognostic advantage for defined risk groups by lymphocyte dissection. Long-term study of 3,616 melanoma patients]

Nine medical centres with different practices in elective lymph node dissection (ELND) but comparable standards regarding diagnosis, excision of the primary tumour, classification, and follow-up, have collected their data on 3616 patients with primary melanoma of the skin (tumour category pT 2 to pT 4a, N 0, M 0 [UICC 1987] with the aim of producing an unbiased analysis of the prognostic benefit of ELND. The multivariate risk analysis (Cox's proportional hazard model) revealed tumour thickness (Breslow or alternative pT categories), sex, anatomic site of the primary tumour, and ELND therapy ("yes" or "no") as independent prognostic factors. Observed survival curves (Kaplan-Meier) show a significant difference of prognosis with regard to ELND therapy in the following risk groups: women with melanomas over 2.5 to 4 mm thick on head, neck, thorax, and in acral locations; men with melanomas over 1.5 to 4 mm thick on head, neck, thorax, and in acral locations; and finally men with melanomas over 2.5 to 4 mm thick on abdomen and extremities. Further investigations and the discovery of additional prognostic factors would help in more precisely formulation of guidelines for ELND.

[Is acrolentiginous melanoma (ALM) more malignant than superficially spreading melanoma (SSM) at a high-risk site? A matched-pair comparison between 113 ALM and SSM within the scope of a multicenter study]

Even today, the prognosis of acrallentiginous melanoma (ALM) remains a controversial topic. We present a large case study including all known factors relevant for prognosis. 113 ALMs in 3616 melanoma patients were paired as precisely as possible with their twins, i.e. with 113 superficial spreading melanomas (SSM) from a group of 619 SSMs with high-risk location. The ALMs and SSMs were equivalent in tumor thickness, patient gender and mode of treatment. The follow-up period was for at least 5 years. The 5-year Kaplan-Meier survival curve in both groups are identical. The poor prognosis often ascribed to ALM results from the prognostic factor location. ALM should therefore be regarded as acral localized melanoma.

[Extremity perfusion in malignant melanoma]

Isolation perfusion was introduced in 1957 by Creech and Krementz for treatment of in-transit metastases from malignant melanoma of the limbs. The isolation of the extremity from the body circulation allows a high concentration of cytostatics without systemic side effects. In combination with hyperthermic tissue temperatures around 41.5 degrees C an additional effect can be expected. Regional metastasizing malignant melanomas with satellites, in-transit or lymph node metastases are generally accepted indications for isolation perfusion. There is still controversy about elective adjuvant perfusion in stage I melanoma. In spite of performing this treatment modality over 40 years in practice there are still many factors under discussion and many problems to be solved. The surgical procedure and techniqual aspects are described in detail. Krementz demonstrated long term survival rates between 19% and 53%. The patients treated in the Surgical Department of the University Hospital in Erlangen since 1975 with satellites and in-transit metastases had a 10-year survival rate of 48%. Considering the historical data of our patients without perfusion with a 10-year survival of 11% there is a highly significant statistical difference. In conclusion isolation perfusion is the therapy of choice in patients with locally metastasized malignant melanoma of the limbs.