Oncological outcome after MRI-based selection for neoadjuvant chemoradiotherapy in the OCUM Rectal Cancer Trial

BACKGROUND

It is not clear whether all patients with rectal cancer need chemoradiotherapy. A restrictive use of neoadjuvant chemoradiotherapy (nCRT) based on MRI findings for rectal cancer was investigated in this study.

METHODS

This prospective multicentre observational study included patients with stage cT2-4 rectal cancer, with any cN and cM0 status. Carcinomas in the middle and lower third that were 1 mm or less from the mesorectal fascia, all cT4 tumours, and all cT3 tumours of the lower third were classified as high risk, and these patients received nCRT followed by total mesorectal excision (TME). All other carcinomas with a minimum distance of more than 1 mm from the mesorectal fascia and those in the upper third were classified as low risk; these patients underwent TME alone (no nCRT). Patients were followed for at least 3 years. Outcomes were the rates of local recurrence, distant metastasis and survival.

RESULTS

Among 545 patients included, 428 were treated according to the study protocol: 254 (59·3 per cent) had TME alone and 174 (40·7 per cent) received nCRT and TME. Median follow-up was 60 months. The 3- and 5-year local recurrence rates were 1·3 and 2·7 per cent respectively, with no differences between the two treatment protocols. Patients with disease requiring nCRT had higher 3- and 5-year rates of distant metastasis (17·3 and 24·9 per cent respectively versus 8·9 and 14·4 per cent in patients who had TME alone; P = 0·005) and worse disease-free survival compared with that in patients who did not need nCRT (3- and 5-year rates 76·7 and 66·7 per cent, versus 84·9 and 76·0 per cent in the TME-alone group; P = 0·016).

CONCLUSION

Restriction of nCRT to high-risk patients achieved good results.

FDG-PET in the initial staging of squamous cell oesophageal carcinoma

Squamous cell oesophageal carcinoma is the most common carcinoma of the oesophagus worldwide. The tumour stage as most important prognostic factor determines the clinical management. Aim of this study was to evaluate the value of FDG-PET 1. in imaging the primary tumour and 2. in Nand M-staging of squamous cell oesophageal carcinoma. Patients, methods: In 20 patients with histological proven squamous cell carcinoma of the upper and middle oesophagus , FDG-PET was performed in standard technique prior to therapy. FDG uptake in the primary was determined by calculation of the SUVmax. NM-staging due to PET findings was performed as designated by the AJCC/UICC group classification and was compared with pathological and clinically based staging. Sensitivities, specificities and accuracies were calculated. Results: In 19 of 20 patients, primary squamous cell oesopohageal carcinoma was detected by FDG-PET findings with a maximum SUV of 12.5 (mean) ± 5.1 (median 11.5; range 4.8-23.8). One carcinoma in situ was missed. The sensitivity of FDG-PET in imaging the primary tumour was 96%. The sensitivities, specificities and accuracies were 20%, 100%, 58% for N-staging, and 60%, 86% and 93% for M-staging. PET findings caused changes of therapy in 5% (1 patient). Conclusions: FDGPET was excellent in imaging the primary of squamous cell oesophageal carcinoma in stage T1-T4 and was efficient in M-staging. The low sensitivity in N-staging is of inferior clinical importance. The efficacy of FDG-PET seems to be not significantly be influenced by the histological subtype of oesophageal carcinoma.

Long-term results of transanal endoscopic microsurgery after endoscopic polypectomy of malignant rectal adenoma

BACKGROUND

There is no consensus on the treatment and prognosis of malignant rectal polyps. The aim of the present study was to determine the role of transanal endoscopic microsurgery (TEM) after endoscopic complete polypectomy of malignant rectal adenomas with long-term follow-up.

METHODS

Of 105 patients with pT1 rectal carcinoma in 32 patients TEM followed complete endoscopic polypectomy while 73 had primary TEM. Local recurrence (LR), distant metastasis, overall and cancer-specific survival were determined by the Kaplan-Meier method.

RESULTS

Median follow-up was 9.1 years. In 32 patients with TEM following complete polypectomy no residual cancer was found. LR occurred in 3/28 (11%) patients with low-risk carcinoma (pT1 G1/2/X, L0/X, R0) and in 1/4 (25%) with high-risk carcinoma (pT1 G3/4 or L1). After primary TEM with complete resection (minimal distance >1 mm) LR occurred in 6/60 (10%) with low-risk carcinoma. After incomplete TEM resection (minimal distance ≤1 mm) LR occurred in 3/8 (38%) patients with low-risk and in 1/5 (20%) patients with high-risk carcinoma. Grading was the only significant risk factor for LR after endoscopic polypectomy followed by TEM (p = 0.002). At all outcomes did not differ between postpolypectomy TEM and primary TEM.

CONCLUSIONS

Patients with malignant rectal polyps removed by endoscopic polypectomy have a substantial risk of LR even if TEM of polyp site is cancer free. Risk of LR depends on tumor characteristics. In low-risk carcinoma long-term follow-up is necessary. The high LR rate in patients with high-risk rectal carcinoma restricts the use of TEM alone.

[Spincter preservation after selective chemoradiotherapy of rectal cancer. Interim results of the OCUM study]

BACKGROUND

In a prospective multicenter observational study (OCUM) neoadjuvant chemoradiotherapy (nRCT) was selectively administered depending on the risk of local recurrence and based on the distance between tumor and mesorectal fascia in pretherapeutic high-resolution magnetic resonance imaging (MRI).

OBJECTIVE

Frequency and quality of abdominoperineal excision (APE) and sphincter preserving operations.

PATIENTS AND METHODS

Of 642 patients treated in 13 hospitals 389 received surgery alone and 253 nRCT followed by surgery. By univariate and multivariate analysis risk factors for APE were determined. Quality parameters were the quality grade of mesorectal excision, the pathohistological involvement of the circumferential resection margin and intraoperative local dissemination of tumor cells.

RESULTS AND DISCUSSION

In 12.8 % of the patients APE was performed. Independent risk factors for APE were tumor location in the lower third of the rectum and the individual hospitals, where APE varied between 0 and 32 %. This variation was chiefly caused by the different case mix. Hospitals with a high APE rate (> 30 %) treated significantly more patients with very low lying carcinomas (< 3 cm above the anal verge) and more advanced tumors. The median height of the tumor in cases of APE was nearly equal in all participating hospitals. Independent on the number of cases the quality of rectal surgery was high. Within the patient groups of primary surgery and nRCT the oncological quality parameter did not significantly differ between sphincter preservation and APE. As far as sphincter preservation is concerned the results justify a selective application of nRCT in patients with rectal carcinoma. The long-term results still have to be awaited.

[Lymph node dissection after primary surgery and neoadjuvant radiochemotherapy of rectal cancer. Interim analysis of a multicenter prospective observational study (OCUM)]

INTRODUCTION

The OCUM trial (NCT01325649) aims to clarify whether low rates of local recurrence are also achieved when the indications for neoadjuvant radiochemotherapy are not based on the clinical TNM staging but on preoperative magnetic resonance imaging with measurement of the tumor distance to the circumferential resection margin. In this interim analysis the lymph node status in OCUM patients was investigated as a surrogate parameter for quality of surgery and histopathological work-up.

MATERIAL AND METHODS

Until now a total of 560 patients have been included in this study. Total mesorectal excision (TME) without pretreatment was undertaken in 338 patients (60.4 %) and neoadjuvant radiochemotherapy was administered in 222 (39.6 %) patients. The histological work-up was performed according to the guidelines of the German Association of Pathologists. Data are given as median values and ranges in brackets.

RESULTS

The lymph node yield was 24 (7-79) in 338 patients undergoing primary TME surgery without pretreatment, while 20 (3-56) lymph nodes were identified in patients after neoadjuvant radiochemotherapy (p = 0.001). A minimum of 12 lymph nodes were analyzed in 335 out of 338 patients (99.1 %) and in 209 out of 222 patients (94.1 %) following neoadjuvant radiochemotherapy (p = 0.001). Lymph node metastasis was identified (p = 0.362) in 116 out of 338 patients without pretreatment (34.3 %) and in 71 out of 222 patients after neoadjuvant radiochemotherapy (32.0 %). Patient age did not influence the number of identified lymph nodes or rate of lymph node metastasis.

CONCLUSION

In this trial the number of identified lymph nodes suggests that the quality of surgery and histopathological work-up were adequate compared to the standards defined by national guidelines. Neoadjuvant radiochemotherapy led to a reduced lymph node yield compared to surgery without pretreatment; however, this did not influence the rate of lymph node metastasis.

Use of Preoperative Magnetic Resonance Imaging to Select Patients with Rectal Cancer for Neoadjuvant Chemoradiation--Interim Analysis of the German OCUM Trial (NCT01325649)

INTRODUCTION

Introduction of total mesorectal excision (TME) surgery for rectal cancer decreased local recurrence dramatically. Additional neoadjuvant chemoradiation (nCR) is frequently given in UICC II and III tumors based on TNM staging which is of limited accuracy. We aimed to evaluate determination of circumferential margin by magnetic resonance imaging (mrCRM) as an alternative criterium for nCR.

METHODS

Multicenter prospective cohort study which enrolled 642 patients in 13 centers with non-metastasized rectal adenocarcinoma. Patients with T4 tumors or patients with a mrCRM of 1 mm or less were treated by neoadjuvant chemoradiation. All others proceeded directly to surgery when inclusion criteria and no exclusion criteria were met. Quality of TME and accuracy of mrCRM determination were assessed during pathology workup.

RESULTS

TME was complete in 381 of 389 patients after surgery without nCR (97.9%) and in 245 of 253 patients (96.8%) after nCR. Negative pathology circumferential margins (pCRM) were seen in 97.4% without nCR and in 89% of patients after nCR. Negative pCRM was predicted by negative mrCRM in 98.3% of rectal cancers. NCR was given to 253 of 642 patients (39.5%). Lymph node count was 23 (range 7-79; median/range) for surgery without nCR and 19 (range 2-56) for surgery after nCR.

CONCLUSIONS

Surgical quality determined by pathology workup of specimen was very good in this study. Magnetic resonance imaging guided indication for nCR allows to achieve superb results concerning surrogate parameters for good oncological outcome. Thus, use of neoadjuvant chemoradiation with its potential detrimental side effects may be substantially reduced in selected patients.

The prognostic value of lymph node ratio and updated TNM classification in rectal cancer patients with adequate versus inadequate lymph node dissection

BACKGROUND

The aim of this study was to clarify whether the lymph node ratio (LNR) is superior to the updated TNM classification regarding the prognosis of stage III rectal cancer patients who have not undergone neoadjuvant therapy. The TNM system is based on the absolute number of lymph nodes involved, and the LNR takes into account involved and examined nodes.

METHODS

In 237 patients with stage III rectal cancer, we evaluated prognostic factors for 5-year overall survival (OS), disease-free survival (DFS), and risk of distant metastases (DM) using the Kaplan-Meier method, with patients divided based on adequate versus inadequate lymph node dissection (≥12 vs. <12 lymph nodes examined). The updated TNM divides patients into four groups (1, 2-3, 4-6, and ≥7 involved nodes), while LNR divides patients into quartiles. Multivariate Cox regression analyses were performed.

RESULTS

Among patients with adequate lymph node dissection, the distributions within the two systems were in agreement in 141/178 (79.2 %, kappa 0.721), and the predictive values for OS, DFS, and DM were similar. In patients with inadequate lymph node dissection, the classifications of both systems were concordant in only 13/59 (22 %, kappa 0.021). The pN system significantly under-staged patients, while the LNR classification was a better predictor of OS, DFS, and DM.

CONCLUSIONS

In patients with adequate lymph node dissection, LNR staging does not add substantial information to the predictions of updated TNM lymph node staging. However, in patients with inadequate lymph node harvesting, the LNR compensates for the under-staging of the TNM classification and provides a better estimation of prognosis than the updated TNM system.

[Quality indicators of diagnosis and therapy in MRI-based neoadjuvant radiochemotherapy for rectal cancer - interim analysis of a Prospective Multicentre Observational Study (OCUM)]

BACKGROUND

The interim analysis of a prospective multicentre observational study of selective neoadjuvant chemoradiotherapy (OCUM) in patients with rectal cancer should evaluate the quality of diagnosis and therapy as a prerequisite for continuation of the study.

PATIENTS AND METHODS

230 patients with the clinical stage cT2 - 4, each cN, M0 with radical tumour resection were enrolled until now. The values of 13 quality indicators were compared with the target values formulated by the workflow of the Working Group rectal cancer II and the German Cancer Society and were also compared with the results of the certified bowel centres of Germany 2010.

RESULTS

The target values were fulfilled to a high degree regardless of caseload. 83 % of parameters have been fully achieved and 14 % nearly achieved. In primary surgery the proportion of patients with 12 or more histologically examined lymph nodes was 99.2 %, after neoadjuvant chemoradiotherapy 90 %. A R0 resection was performed in 98.3 % and a resection of TME in muscularis propria plane only in 2.2 %. The rate of positive circumferential resection margins (pCRM + ) was 5.7 % only.

CONCLUSIONS

The high quality of rectal surgery justifies the concept and the continuation of the study.

Extension of the measurement capabilities of the quadrupole resonator

The quadrupole resonator, designed to measure the surface resistance of superconducting samples at 400 MHz has been refurbished. The accuracy of its RF-dc compensation measurement technique is tested by an independent method. It is shown that the device enables also measurements at 800 and 1200 MHz and is capable to probe the critical RF magnetic field. The electric and magnetic field configuration of the quadrupole resonator are dependent on the excited mode. It is shown how this can be used to distinguish between electric and magnetic losses.

Oncological short-term effects and adverse events of MRI-guided selective neoadjuvant radiochemotherapy for rectal cancer

AIM

To investigate the oncological short-term effects and acute side-effects of magnetic resonance imaging (MRI)-guided selective neoadjuvant radiochemotherapy (nRCT) for rectal cancer.

PATIENTS AND METHODS

In a prospective multicenter cohort study of 230 patients with rectal cancer stage II or III, nRCT was applied in the following situations (n=96) only: cT4 tumors, cT3 tumors of the distal rectum or tumors leaving a circumferential resection margin (CRM) of ≤1 mm between the tumor and the mesorectal fascia (mrCRM+). Pre-therapeutical tumor stage and involvement of mesorectal fascia were assessed by MRI and were compared with the pathological findings of the rectal specimens. Furthermore, tumor regression grades, acute side-effects, and surgical complications were analysed.

RESULTS

Using selective nRCT, 62 out of 72 patients (86%) with mrCRM+ had tumor-negative pathological CRM. Reduction of T category was observed in 62% and of N category in 88% of patients. Lymph node metastasis was found by pathology in only 21% of all irradiated patients. Histologically complete tumor regression (ypT0ypN0) was observed in 15% and intermediate regression (more than 25%, but not complete) in 67% of patients. Fifteen percent of patients suffered from grade 3 toxicity, but no grade 4 toxicity occurred. nRCT did not adversely influence surgical morbidity.

CONCLUSION

Despite the negative selection of locally advanced rectal cancer cases for nRCT, impressive rates of tumor down-staging and eradication of tumor from the mesorectal fascia were achieved. The rate of complete regression is comparable to that in the literature. Moreover, the selective use of nRCT spared a considerable percentage of patients with stage II/III rectal cancer severe irradiation toxicity.

[Palliative care for patients with oesophageal cancer]

BACKGROUND

Palliative therapy for patients with incurable oesophageal cancer necessitates a broad spectrum of different measures to relieve symptoms.

METHODS

Surgical procedures (palliative tumour resections, bypass surgery) are rarely indicated on account of the high morbidity. Preeminent treatment options to eliminate dysphagia and to ensure food passage are endoscopic procedures, in particular, the endoscopically or radiologically guided stent implantation. In case of failure, a percutaneous feeding tube and general palliative measures are required. Furthermore tumour-specific therapies (brachytherapy, radiochemotherapy, chemotherapy) are applied.

DISCUSSION

The choice of the procedure is based on the symptoms, the tumour situation, the patients' general status, and their preferences. If possible, an individual, interdisciplinary treatment concept for each patient should be designed and modified according to the course of the disease.

CONCLUSIONS

It should be the aim of future studies to elucidate the optimal combination of a merely symptomatic treatment with tumour-specific measures under the aspect of the achievable quality of life.

[The optimult study concept - selective neoadjuvant chemoradiation therapy based on preoperative MRI]

Optimal surgery for rectal cancer, i. e., total mesorectal excision in the middle and lower rectum reduces local recurrence substantially. Multi-modal therapy further improves the rate of local recurrence in advanced rectal cancer. In Germany neoadjuvant chemoradiation therapy is most frequently given for these tumours. However, clinical staging by endosonography, CT scan and / or MRI is unreliable, particulary as regards lymph node category, which entails overtreatment of a relevant number of patients secondary to overstaging. Thus, a subgroup of patients has to tolerate side effects and long-term sequelae of neoadjuvant therapy without having oncological benefit from this pretreatment. It is of note that the prognosis of patients with advanced rectal cancer depends not only on the T and N category but also on the free circumferential margin of the tumour as determined by pathological examination. In contrast to the T and N category, the latter may be predicted before treatment by pelvic MRI. While several case series demonstrated that low local recurrence rates are achieved in patients when preoperative MRI showed free circumferential margins, this concept was never tested in a randomised controlled trial. We, therefore, designed a two-armed randomised study with patients who suffer from rectal cancer and who have 2 mm or more free circumferential margins on their preoperative MRI. These patients are either operated without pretreatment (intervention arm) or receive neoadjuvant chemoradiation therapy with subsequent surgery (control arm). If local recurrence in the intervention arm is not inferior to the control arm, this study may form the basis for an individualised therapeutic concept for rectal cancer based on preoperative MRI. Potentially, chemoradiation therapy may be avoided in the future for patients who will have no oncological benefit from this treatment modality.

Treatment of metachronous and simultaneous liver metastases of pancreatic cancer

AIM

Patients were analyzed who underwent treatment of liver metastases from pancreatic cancer.

METHODS

Selection criteria were the possibility of R0 resection of the primary and/or the liver metastases, no other sites of metastases, and the presentation of liver metastases. A comparison of treatment by surgery versus chemotherapy regarding overall survival and disease-free interval was performed.

RESULTS

Between 1996 and 2008, a total number of 23 patients were retrospectively identified from a prospective database of 193 cases of pancreatic cancer. In 14 cases, liver metastases were found simultaneously, and in 9 cases metachronously, fulfilling the abovementioned selection criteria. Of these, 13 patients underwent surgery and 10 were treated by gemcitabine. There were no differences in survival in patients with synchronous liver metastases of pancreatic cancer treated by resection of the primary combined with partial hepatectomy versus treatment by gemcitabine (8 vs. 11 months). In patients with metachronous liver metastases, the median survival was increased after liver resection compared to patients who were treated with gemcitabine (31 vs. 11 months).

CONCLUSIONS

Simultaneous resection of pancreatic cancer and liver metastases cannot be recommended. Resection of metachronous liver metastases of pancreatic cancer seems to improve survival in highly selected patients.

[Diagnosis of and therapy for gastric cancer--work-flow]

AIM

This review comments on the diagnosis and treatment of gastric cancer in the classical meaning--excluding adenocarcinoma of the -oesophagogastric junction. Algorithms of diagnosis and care with respect to tumour stage are presented. PREOPERATIVE DIAGNOSIS: Besides oesophagogastroduodenoscopy, endoscopic ultrasonography is necessary for the accurate diagnosis of T categories and as a selection criterion for neoadjuvant chemotherapy. Computed tomography is recommended for preoperative evaluation of tumours > T1, laparoscopy has become an effective stag-ing tool in T3 and T4 tumours avoiding unnecessary laparotomies and improving the detection of small -liver and peritoneal metastases.

TREATMENT

Endoscopic mucosal resection and submucosal dissection are indicated in superficial cancer confined to the mucosa with special characteristics (T1 a / no ulcer / G1, 2 / Laurén intestinal / L0 / V0 / tumour size < 2 cm). In all other cases total gastrectomy or distal subtotal gastric resection are indicated, the latter in cases of tumours located in the distal two-thirds of the stomach. Standard lymphadenectomy (LAD) is the D2 LAD without distal pancreatectomy and splenectomy. The Roux-en-Y oesophagojejunostomy is still the preferred type of reconstruction. An additional pouch reconstruction should be considered in -patients with favourable prognosis, this also -applies for the preservation of the duodenal passage by jejunum interposition. Extended organ resections are only indicated in cases where a R0-resection is possible. Hepatic resection for metachronous or synchronous liver metastases is rarely advised since 50 % of patients with liver metastases show concomitant peritoneal dissemination of the disease.

DISCUSSION AND CONCLUSIONS

Undergoing gastrectomy at a high-volume centre is associated with lower in-hospital mortality and a better prognosis, however, clear thresholds for case load cannot be given. Perioperative chemotherapy and postoperative chemoradiotherapy are based on the MAGIC and MacDonald trials. Perioperative chemotherapy should be performed in patients with T3 and T4 tumours with the aim to increase the likelihood of curative R0-resection by downsizing the tumour. Adjuvant postoperative chemotherapy cannot be recommended since its benefit has so far not been proven in randomised trials. In selected patients with incomplete lymph-node dissection and questionable R0-resection postoperative chemoradiotherapy may be debated.

[Rectal melanoma: the value of modern treatment]

Rectal melanoma is a rare disease. There is much controversy concerning cause, incidence and treatment of the disease and the spreading of recurrence. In this article, we discuss actual aspects of diagnostic, therapy and prognosis on the basis of our series of seven patients as well as a literature review. The surgical therapy in the form of local tumour excision with a disease-free margin of up to 1-2 cm is the initial therapeutic modality of choice. Large tumours that obviously could not be removed in sano should be treated with a multimodal concept. Such tumours should be treated by a combination of neoadjuvant radiation and chemotherapy for down-staging with subsequent local excision (LE) or abdomino-perineal rectum extirpation (APR). An inguinal lymphadenectomy should only be performed if the lymph nodes are enlarged on clinical or radiological examination. The prognosis of rectal melanoma is markedly poor and is primarily related with the stage of disease. The 5-year survival rate is estimated at about 24% for patients with stage I tumours. Patients with stage II and III tumours have appreciably shorter survival times of 12 months on the average.

[Diagnosis and treatment of colorectal liver metastases - workflow]

In this review, standards of diagnosis and treatment of colorectal liver metastases are described on the basis of a workshop discussion. Algorithms of care for patients with synchronous / metachronous colorectal liver metastases or locoregional recurrent tumour are presented. Surgical resection is the procedure of choice in the curative treatment of liver metastases. The decision about the resection of liver metastases should consider the following parameters: 1. General operability of the patient (comorbidity); 2. Achievability of an R 0 situation: i. if necessary, in combination with ablative methods, ii. if necessary, neoadjuvant chemotherapy, iii. the ability to eradicate extrahepatic tumour manifestations; 3. Sufficient volume of the liver remaining after resection ("future liver remnant = FLR): i. if necessary, in combination with portal vein embolisation or two-stage hepatectomy; 4. The feasibility to preserve two contiguous hepatic segments with adequate vascular inflow and outflow as well as biliary drainage; 5. Tumour biological aspects ("prognostic variables"); 6. Experience of the surgeon and centre! Extrahepatic disease does not contraindicate hepatectomy for colorectal liver metastases provided a complete resection of both intra- and extrahepatic disease is feasible. Even in bilobar colorectal metastases and 5 or more tumours in the liver, a complete tumour resection has been described. The type of resection (hepatic wedge resection or anatomic resection) does not influence the recurrence rate. Preoperative volumetry is indicated when major hepatic resection is planned. The FLR should be 25 % in patients with normal liver, 40 % in patients who have received intensive chemotherapy or in cases of fatty liver, liver fibrosis or diabetes, and 50-60 % in patients with cirrhosis. In patients with initially unresectable colorectal liver metastases, preoperative chemotherapy enables complete resection in 15-30 % of the cases, whereas the value of neoadjuvant chemotherapy in patients with resectable liver metastases has not been sufficiently supported. In situ ablative procedures (radiofrequency ablation = RFA and laser-induced interstitial thermotherapy = LITT) are local therapy options in selected patients who are not candidates for resection (central recurrent liver metastases, bilobar multiple metastases and high-risk resection or restricted patient operability). Patients with tumours larger than 3 cm have a high local recurrence rate after percutaneous RFA and are not optimal candidates for this procedure. The physician's experience influences the results significantly, both after hepatectomy and after in situ ablation. Therefore, patients with colorectal liver metastases should be treated in centres with experience in liver surgery.

[Indications for conventional adrenalectomy]

INTRODUCTION

Conventional adrenalectomy still plays an important role, even in the era of minimally invasive endocrine surgery. It was the aim of our study to analyse the indications for conventional adrenalectomy in our own patients since the introduction of the minimally invasive technique in the year 1994 - laparoscopically and retroperitoneoscopically.

PATIENTS AND METHODS

Between January 1994 and September 2006, a total of 412 adrenalectomies were performed in 380 patients. Out of these, 106 operations (25.7 %) were carried out conventionally in 98 patients, and 306 operations (74.3 %) endoscopically in 282 patients.

RESULTS

Indications for conventional adrenalectomy were - as compared with the minimally invasive procedure - significantly more frequent adrenocortical carcinomas (ACC), especially in the context of multivisceral resections, as well as adrenal metastases (synchronous and metachronous). In contrast, adrenal Cushing's disease (including 19 patients with bilateral tumours), pheochromocytoma, incidentaloma and Conn's syndrome constituted a more frequent indication for minimally invasive adrenalectomy. Conventionally operated adrenal pathologies with on average 6.0 (range: 1.2-19.0) cm diameter were significantly larger than the endoscopically removed tumours with on average 3.3 (range: 0.2-9.2) cm diameter (p < 0.0001). The side localisation and the frequency of bilateral adrenal tumours did not differ significantly in the two groups.

CONCLUSION

Since the establishment of the minimally invasive technique in 1994, conventional adrenalectomy has been selected for 26 % of all resected adrenal pathologies at our clinic and, therefore, still plays an important role even in the era of laparoscopic surgery. The benefit of the laparoscopic procedure in the case of malignant pheochromocytoma, adrenocortical carcinoma, and isolated adrenal metastases at a locally confined stage is still unclear and requires prospective, randomised studies.

[Achalasia or pseudoachalasia? Problems of diagnostic and treatment decisions in two cases]

HISTORY

Patient 1 (female, aged 55 years) had for some time complained of morning nausea. She reported symptoms of reflux with regurgitation of food for two-and-a-half years and also dysphagia with retrosternal bolus obstruction for the last eighteen months. Patient 2 (male, aged 84 years) complained of restrosternal dysphagia with each intake of food for one year, weight loss of 12 kg and occasional regurgitation of food.

INVESTIGATIONS

The general condition of patient 1 was only slightly impaired but that of patient 2 markedly reduced. Routine laboratory tests were unremarkable in both. Barium meal in patient 1 revealed fixed narrowing in the region of the esophageal hiatus. The inferior esophageal sphincter was closed but opened under pressure during esophagogastroscopy. At computed tomography (CT) of the thorax and abdomen an esophageal fistula was detected and bronchoscopy confirmed its opening into the esophagus. Barium meal in patient 2 (done at another hospital) demonstrated a spastic esophagus. Manometry of the esophagus revealed at rest an abnormal increase in the inferior esophageal sphincter without relaxation.

DIAGNOSIS, TREATMENT AND COURSE

Patient 1 had an achalasia and an esophagogastric fistula with recurrent aspiration pneumonia, bronchial carcinoma being excluded. The fistula was closed by suture, followed by cardiomyotomy and anterior partial gastric fundectomy. In patient 2 an isolated achalasia had at first been suspected and botulinum toxin injected into the inferior esophageal sphincter. This caused a progressively worse dysphagia. CT of the thorax and abdomen established the diagnosis of a pseudoachalasia due to an adenoma of the cardia, proven by biopsy at an exploratory laparotomy. A stent was implanted in the esophagus: the postoperative course was without complication.

CONCLUSION

Patient 2 with the pseudoachalasia had a relatively short history of dysphagia, marked weight loss and was elderly. This compares with the history in patient 1: shorter period of dysphagia, no weight loss and a younger age. The differential diagnosis between the two conditions may be difficult with routine methods and other imaging modalities: exploratory surgery may be necessary for a definitive diagnosis.

The multidisciplinary management of gastrointestinal cancer. Multimodal treatment of gastric cancer

Although radical surgical R0 resections are the basis of cure for gastric cancer, surgery alone only provides long-term survival in 20-30% of patients with advanced-stage disease. Thus, in Western and European countries, advanced gastric cancer has a high risk of recurrence and metachronous metastases. Very recently, multimodal strategies combining different neoadjuvant and/or adjuvant protocols have improved the prognosis of gastric cancer when combined with surgery with curative intent. As used in palliative regimens, the combination of cisplatin with intravenous or oral fluoropyrimidines has been the integral component of such (neo)adjuvant strategies. However, the cytotoxic agents docetaxel, oxaliplatin and irinotecan and new targeted biologicals such as cetuximab, bevacizumab or panitumumab are currently under investigation, with or without irradiation, in multimodal treatment regimens. These studies may further increase R0 resection rates, and prolong disease-free and overall survival times in the treatment of advanced gastric cancer. This article reviews the most relevant literature on multimodal treatment of gastric cancer, and discusses future strategies to improve locoregional failures.

Long-term urinary dysfunction after mesorectal excision: A prospective study with intraoperative electrophysiological confirmation of nerve preservation

BACKGROUND

Bladder dysfunctions are well-recognized complications after nerve-sparing mesorectal excision for rectal cancer. This study sought to symptomatically analyze the extent of recovery from major and minor urinary symptoms in patients with signs of bladder denervation.

METHODS

Sixty-two patients with mesorectal excision for rectal cancer were investigated prospectively. Pelvic autonomic nerve preservation (PANP) was assessed macroscopically and with the aid of intraoperative electrical stimulation of pelvic autonomic nerves (INS). Bladder function was evaluated with the International Prostate Symptom Score (IPSS) and the Quality of life index (Qol). Median follow-up was 20 months (range 3-40 months).

RESULTS

Forty-six patients with INS-confirmed preservation of parasympathetic nerves remained unchanged in early and long-term urinary function (IPSS: median 1; range 0-24 and Qol 0; range 0-5). In 15 patients without confirmation of PANP (unilaterally or bilaterally) on INS, voiding function was significantly more impaired postoperatively (IPSS: median 10; range 0-25 and Qol 3; range 0-6) and at long-term follow-up (IPSS: median 9; range 0-25 and Qol 3; range 0-6) (p<0.001). Voiding function was improved in 4 of 10 patients with major and minor symptoms. In 5 of 6 patients with long-term bladder dysfunction INS assessed parasympathetic nerve damage unilaterally (3/5) and bilaterally (2/5).

CONCLUSION

Long-term voiding disturbance after mesorectal excision was found to be a serious complication. INS while monitoring intravesical pressure is a valuable aid in predicting long-term bladder function after TME. The device may serve a secondary preventive function in enabling the initiation of early urologic therapy.

[Obesity surgery in patients suffering from monogenetic adipositas]

Surgical treatment of patients suffering from monogenetic forms of morbid obesity is considered to be the poorest investigated theme in bariatric surgery. This review article presents aspects of genetic disorders in morbid obesity as well as some aspects of surgical treatment in patients with monogenetic forms of morbid obesity (Prader-Willi-Syndrome). Gastric restrictive procedures such as vertical banded gastroplasty or adjustable gastric banding as well as malabsorptive and mix procedures such as biliopancreatic diversion or Roux-en-Y gastric bypass are used for treatment, similar to polygenetic forms of morbid obesity. Until to now there is no evidence-based data because of the small number of published cases. Decisions about the indication to operation and about the choice of surgical procedures are based on the empiric fundament. It is to suggest that the use of growth hormones in patients with monogenetic forms of morbid obesity could positively influence the results of bariatric surgery in these patients.

Transarterielle Chemoembolisation (TACE) des Hepatozellulären Karzinoms (HCC) bei Patienten mit Pfortaderthrombose - Erfahrungen

PURPOSE

Comparative analysis of the course of disease in patients with initial diagnosis of portal vein thrombosis in HCC treated with sequential TACE. Evaluation of the efficacy and safety of the method in a selected patient cohort.

PATIENTS AND METHODS

The study included 22 patients with HCC that were palliatively treated at least 3 times with TACE. All patients presented a portal vein thrombosis in the initial CT investigation. The TACE-procedure was carried out in regular intervals using a suspension consisting of a fixed dosage of Mitomycin C (10 mg) and 10-20 ml Lipiodol. Follow-up investigations were carried out with contrast enhanced Multislice-CT before and after TACE and control of the laboratory panel (i. e. blood count, liver enzymes and coagulation).

RESULTS

Mean survival was 15.7 months (95%-CI 11.6-19.8) with a mean follow-up after last TACE of 6.1 +/- 4.8 months. The mean number of TACE procedures was 5.5 +/- 2.7. During the investigation period 17 / 22 (77.3%) patients died. In 23.5% retrospective analysis revealed a liver decompensation as the cause of death and in 58.8% patients died from the tumor disease. The cumulative 1-, 2- and 3-year survival was 55.0, 21.0 and 0%. The mean tumor size was 7.2 +/- 3.4 cm. Unifocal tumors were found in 18.2% of the cases whereas multifocal tumors were found in 81.8%. In 59.1% of the patients tumor extended to both liver lobes. In case of tumor infiltration of the portal vein survival was significantly worse compared to patients with no evidence of a tumor thrombosis (p = 0.01; cumulative 1- and 2-year survival 46% and 8% vs. 77% and 46%).

CONCLUSION

The palliative treatment of the HCC with TACE shows an improvement of survival. There was no increase of death due to liver decompensation in our cohort. Patients with a tumor infiltration of the portal vein showed a significantly worsened survival. The presence of a portal vein thrombosis at the initial diagnosis of the HCC is not an absolute contraindication for TACE treatment but patients have to be elected carefully with critical regard to their liver function.

Lebermetastasen kolorektaler Karzinome - wie oft kann man operieren?

Recurrent liver metastases of colorectal carcinoma are frequent. The repeat hepatectomy is superior to other therapeutic options. In about 20% of patients with recurrent liver metastases a complete resection (R0) is possible. The morbidity of repeat hepatectomy is similar to that of first hepatectomy. The 5-year survival rate after repeat hepatectomy ranges between 30 and 40%. Often in the follow-up additional operations become necessary for extrahepatic recurrencies. For determination of the optimal therapy an interdisciplinary approach must be chosen.

Hepatocellular Injury of Nonischemic Liver Tissue after Selective Clamping in Rats – Protective Action by Pharmacological Pretreatment with Lipoic Acid

BACKGROUND/AIM

The aim of the study was to characterize the hepatic injury (HI) of the nonischemic liver lobe after selective portal triad clamping and investigate the influence of pharmacological pretreatment with alpha-lipoic acid (LA).

METHODS

Brown-Norway rats received 500 micromol LA injected via the inferior vena cava 15 min prior to the induction of 90 min of selective ischemia. Another group of rats received vehicle prior to ischemia. Both groups were compared with sham-operated animals.

RESULTS

Lipid peroxidation (LPO) was increased in the ischemic as well as in the nonischemic liver tissue (NIL) in the untreated group. Levels of adenosine triphosphate and reduced glutathione content of the nonischemic liver lobe were decreased in the untreated group 1 h after reperfusion. Activity of caspases 3 and 8 was not detectable, whereas expression of the Bax protein was demonstrated in the NIL. We observed areas of necrotic hepatocytes and large gaps of sinusoids in the NIL of the untreated rats. LA attenuated LPO as well as Bax expression in the NIL. Moreover adenosine triphosphate and glutathione content of the NIL was increased 1 h after reperfusion by LA. LA pretreatment reduced release of alpha-glutathione-s-transferase in plasma. Histology of the nonischemic liver lobe did not markedly differ from sham-operated animals after LA pretreatment.

CONCLUSION

HI of the NIL seems to be mediated by LPO and proapoptotic proteins such as Bax. Besides its described potential to reduce ischemia/reperfusion injury of the ischemic lobe, LA attenuates HI of the nonischemic tissue after selective portal triad clamping.

Intraoperative electrostimulation objectifies the assessment of functional nerve preservation after mesorectal excision

BACKGROUND

To improve nerve-sparing surgery, intraoperative electrical stimulation of pelvic autonomic nerves (INS) has been proposed in urology, gynecology, and visceral surgery. The aim of this study was to assess the impact of INS while monitoring intravesical pressure on the accurate evaluation of pelvic autonomic nerve preservation (PANP) after mesorectal excision. It was sought to determine whether this confirmation is useful in the prediction of postoperative urinary function.

METHODS

Sixty-two patients with mesorectal exzision for rectal cancer were examined prospectively. PANP was assessed visually by the surgeon and with INS. Bladder function was evaluated by post voiding residual volume measurement, rate of recatheterization, rate of long-term urinary catheterisation, and the international prostatic symptom score with quality of life index.

RESULTS

INS confirmed bilateral preservation of parasympathetic nerves in 46 patients (74%), and in 10 patients (16%) in at least one side. In six patients (10%), INS failed to confirm PANP. Eleven patients (18%) developed urinary symptoms postoperatively. INS results had a higher sensitivity than visual assessment by the surgeon (82 vs 46%). Values for specificity ranged at 90 and 92%, respectively. Accuracy of INS in predicting PANP was higher (88 vs 83%). The correlation between urinary function and the findings on INS was good (kappa-value: 0.65), correlation between urinary function and visual assessment by the surgeon was fair (kappa-value: 0.40).

CONCLUSION

INS, while monitoring intravesical pressure, accurately predicts bladder function after mesorectal excision. It may provide further insight into pelvic autonomic nerve sparing techniques.

[Nonerosive and erosive gastroesophageal reflux disease. Long-term results of laparoscopic anterior semifundoplication]

BACKGROUND

The aim of this study was to evaluate long-term results of laparoscopic anterior semifundoplication in patients with nonerosive (NERD) and erosive (ERD) gastroesophageal reflux disease.

PATIENTS AND METHODS

The study includes the period from May 1997 to July 2005. Upper gastrointestinal endoscopy was performed in all 190 patients. The severity of reflux esophagitis was classified according to Savary and Miller (grades I-IV). A standardized questionnaire was used for follow-up, and the modified symptomatic DeMeester score was assessed.

RESULTS

58.5 years of age (range 27-80), patients with nonerosive reflux disease (n=83) were significantly older than those with erosive reflux disease (n=107) (48 years range 15-84) (p=0.0001). Patients with NERD had a lower modified symptomatic DeMeester score postoperatively of 0 (range 0-4) than patients with ERD, of 1 (range 0-5), though without statistical significance (p=0.151).

CONCLUSION

Laparoscopic anterior semifundoplication leads to comparable symptomatic long-term results in both NERD and ERD. Anterior semifundoplication is a good therapeutic option for selected patients with persistent reflux-associated symptoms and endoscopically negative esophagitis.

Male Urogenital Function After Confirmed Nerve-Sparing Total Mesorectal Excision with Dissection in Front of Denonvilliers’ Fascia

This prospective study addresses the rate of male genital dysfunction following total mesorectal excision (TME) for rectal carcinoma using the anterior extramesorectal plane and its correlation with early urinary function, pelvic autonomic nerve preservation (PANP), and intraoperative neurostimulation (INS). A consecutive series of 44 men operated on by the same surgical team was analyzed. After excluding 18 patients considered to be impotent preoperatively, urogenital function was evaluated in 26 patients on the basis of the International Prostatic Symptom Score and International Index of Erectile Function. PANP was assessed with INS of parasympathetic nerves. PANP was complete in 21 patients (80.8%). Deterioration of urinary function was observed in six patients (23.1%) at early follow-up. Postoperative erectile dysfunction assessed in seven patients (26.9%) was associated with micturition disturbances in four (57%). Despite dissection in front of Denonvilliers fascia, the incidence of erectile dysfunction was low in patients with nonanterior tumors (1/10). INS results had higher sensitivity for predicting urinary dysfunction than for predicting erectile dysfunction (67% vs. 43%). Values for specificity and accuracy were 95% and 90%, and 89% and 77%, respectively. The correlation between the findings on INS and urinary function was good (kappa = 0.66) at a fair (kappa = 0.36) correlation for erectile function. Nerve-sparing TME using the anterior extramesorectal plane results in a justifiable rate of postoperative impotence in patients with nonanterior tumors. Patients with negative results on INS or early urinary dysfunction are at greater risk of erectile dysfunction.

[Single center experience over a 5-year period with sequential transarterial chemoembolization (TACE) in the treatment of hepatocellular carcinoma (HCC)]

PURPOSE

To analyze the course of disease of patients treated with sequential TACE and to evaluate the dependent and independent prognostic factors for patient survival using the Cox Proportional Hazard Model.

MATERIALS AND METHODS

94 patients palliatively treated with TACE. Patients were selected if they had been treated at least 3 times. The TACE procedure was carried out at 8-week intervals using a suspension consisting of a fixed dosage of Mitomycin C (10 mg) and 10 ml Lipiodol. Follow-up investigations included contrast-enhanced multislice CT before and after TACE and assessment of the laboratory test results (i. e., blood count, liver enzymes, and coagulation).

RESULTS

In 66.7 % of the patients, multifocal tumors were found. In 16.0 % of the patients, the tumor load represented more then 50 % of the liver volume. In 23.4 % of the cases, a portal vein thrombosis was found in the initial CT scan. The mean survival for the total cohort was 24.1 months (95 %-CI 20.1 - 28.2). During the investigation period, 72/94 of the patients died. The cumulative 1-year, 2-year, and 3-year survival rates are 71.6 %, 33.9 %, und 17.2 %, respectively. A median of 6.0 +/- 3.1 (range 14, n total = 612 TACE) was performed in each patient. A total of 62.5 % patients died because of tumor progression whereas 18.1 % died due to progressive liver failure. Patients in whom the tumor responded to the TACE treatment and who did not develop ascites or those with Okuda stage I or unifocal tumor growth showed a survival benefit whereas the presence of portal vein thrombosis was associated with a significantly poor outcome (p < 0.05). The Child-Pugh stage was not statistically significant for the disease course; the occurrence of new tumor lesions had no influence with regard to 1-year and 2-year survival but had a significant influence on long-term survival (p < 0.05). Independent prognostic factors are (multivariate analysis; p < 0.05): number of TACE performed, tumor type (i. e., unifocal vs. multifocal), response to TACE (response vs. progression), and Okuda stage.

CONCLUSION

Our results emphasize the value of TACE in the palliative treatment of HCC. Under sequential TACE therapy the course of disease in patients suffering from portal vein thrombosis was not significantly worse. Crucial prognostic factors for the course of the HCC are tumor type and extension, response to TACE, and liver function at the beginning of TACE.

Bericht zum 1. Workshop zur lokalen Exzision von Rektumkarzinomen

To determine the significance of local excision (LE) of rectal cancer and discuss oncologic results, a 1st Workshop on LE of rectal cancer was held at the Department of General und Abdominal Surgery, Johannes Gutenberg-University Mainz, Germany. The option of broadening the indication for local excision after neoadjuvant radiochemotherapy (nRCT) of rectal cancer was to be assessed. Local excision of "low risk" T 1 carcinomas was rated as oncologically adequate therapy with good functional results and low complication rates. Transanal endoscopic microsurgical (TEM) resection was the preferrred technique. Pre-requisite for the achievement of low recurrence rates (5 %) is an R0 resection with a safety margin of at least 1 mm (R < or = 1 mm) without tumor fragmentation, because otherwise possible tumor cell displacement and RX resection may not allow an assessment of the resection margin. "high risk" tumors or T 2 carcinomas were not considered an indication for local excision. To identify additional histological risk factors for the oncological outcome (sm-level, tumor budding, mucinous component, perineural infiltration, etc.) the initiation of a multi-center register study (LERC = local excision of rectal cancer) was suggested and is now in preparation. If the finding after TEM resection is not a "low risk" T 1 carcinoma, but a "high risk" situation or a T 2 tumor, immediate reoperation is advised resulting in similar outcomes as compared to primary conventional surgery. A literature analysis of LE after neoadjuvant RCT of T 2/3 rectal cancers showed a local recurrence rate of 0 % for ypT 0 and of 5 % for ypT 1 findings (studies with small patient collectives and short follow-up periods). The lymph node status of T 2 / 3 carcinomas after nRCT is unclear. More advanced/primary not resectable tumors (T 3 / 4) showed lymph node metastases in 5 % for ypT 0 and in 12 % for ypT 1 findings after nRCT, suggesting that for earlier T categories lower rates can be expected. On the basis of these favourable results a prospective multi-center study will be initiated. A study protocol will be established during the 2nd Workshop on LE of rectal cancer in Mainz.

Bericht über den Workshop „Workflow Rektumkarzinom II” am 10. / 11.11.2006 in Burghausen

The task force "workflow rectal cancer II" defined operative techniques in lower rectal cancer, especially the total mesorectal excision and an improved technique of abdominalperineal resection. New aspects for treatment of rectal cancer with primary distant metastases are described. Due to newer publications a concept of bidirectional procedure with surgery and radiochemotherapy is recommended, where the operation must not be inevitably the first step. In anastomoses below 6 cm of the anocutaneous verge a reservoir should be performed on principle due to better functional results. The colon-j-pouch with a maximal loop length of 6 cm is best investigated under these conditions, the other procedures should be further evaluated.

Qualitätsindikatoren bei Diagnostik und Therapie des Rektumkarzinoms

Diagnostic and treatment of rectal cancer need a continuous quality assessment. Indicators of quality were compiled as indicator profile for a summarizing evaluation. The indicators selected should potentially show an appreciable variation of the quality target and in addition should be decisive for the outcome. For the evaluation of the clinical diagnostic the frequency of the determination of the pretherapeutic T, N and M categories and the proportion of pT 1-tumors were chosen, for the pathological diagnostic the number of histologically examined lymph nodes and the proportion of lymphnode positive patients. Process quality of treatment was defined by the following indicators: proportion of tumor excision, of definite therapy by local tumor removal, of neo-adjuvant long-term radiochemotherapy, of adjuvant treatment in patients not selected for neoadjuvant therapy, of total / partial mesorectal excision, of abdomino-perineal resection, postoperative mortality, frequency of clinically apparent anastomotic leakage, and of neurogenic bladder dysfunction at hospital discharge. The indicators for the quality of the performance of treatment were differentiated between surrogate indicators that can be determined immediately after accomplishment of primary surgical therapy giving strong clues for the further course of disease at an early date, and definite indicators. Important surrogate indicators comprise the occurrence of intraoperative local tumor cell dissemination, R 1 / 2-resection, pathohistologically CRM-positive tumor resection, and the quality of mesorectal excision (proportion of incomplete mesorectal excision). The definite indicators include the 5-year local recurrence rate and the 5-year overall survival rate. The corresponding quantifying parameters for the individual indicators are specified in this paper with precise figures.

[Appendicitis necessitatis: appendicitis perforating the abdominal wall]

Perforation of the appendix through the anterior abdominal wall is a rare complication of a frequent disorder. We report on a 37-year old patient presenting with purulent secretion from the right lower abdomen. The CT scan of the abdomen revealed a perityphlitic abscess with perforation of the anterior abdominal wall. The patient underwent laparotomy with appendectomy and subsequent revision of the abdominal wall. Appendicocutaneous fistula due to perforation through the abdominal wall is a rarity. In analogy to empyema necessitatis, which would require the pleural empyema to penetrate the thoracic wall, the entity was denoted appendicitis necessitatis.

Long-term results of endoscopic adrenalectomy for Conn's syndrome

The long-term effect of adrenalectomy on aldosterone-producing adenomas of the adrenal gland is controversially discussed. The aim of this study was to analyze the long-term course, with special consideration of factors of persisting hypertension after endoscopic adrenalectomy, for Conn's syndrome. Between February 1994 and March 2004, 40 patients with Conn's syndrome underwent endoscopic adrenalectomy. Data were recorded prospectively. Adrenalectomy was carried out unilaterally in all patients. Twenty-three patients (57.5%) were women; the median age was 51.7 (31.2-71.4) years. Preoperatively, all patients presented with arterial hypertension persisting over a median period of 84 (5-240) months; 76.3 per cent of the patients had previously been treated with an aldosterone antagonist, and 85 per cent with specific antihypertensives, whereas 52.6 per cent of all patients were under therapy with potassium compounds at the time of admission. After a median follow-up of 45 (7-114) months, potassium substitution was discontinued in 100 per cent of patients, and the aldosterone antagonist was discontinued in 94.7 per cent of patients. In 60.5 per cent of patients, the specific antihypertensive drugs were reduced. Patients with a reduction in antihypertensive medication had, compared with patients without a reduction, a shorter preoperative duration of arterial hypertension and a lower level of serum aldosterone, and were younger. Endoscopic adrenalectomy for Conn's syndrome leads to an immediate normalization of the electrolyte balance postoperatively, whereas hypertension resolves in 60.5 per cent of patients in the long-term course. Thus, the coexistence of essential hypertension or, respectively, a long duration of preoperative hypertension with associated renovascular alterations are of significance for the long-term result.

Long-Term Results of Endoscopic Adrenalectomy for Conn's Syndrome

The long-term effect of adrenalectomy on aldosterone-producing adenomas of the adrenal gland is controversially discussed. The aim of this study was to analyze the long-term course, with special consideration of factors of persisting hypertension after endoscopic adrenalectomy, for Conn's syndrome. Between February 1994 and March 2004, 40 patients with Conn's syndrome underwent endoscopic adrenalectomy. Data were recorded prospectively. Adrenalectomy was carried out unilaterally in all patients. Twenty-three patients (57.5%) were women; the median age was 51.7 (31.2–71.4) years. Preoperatively, all patients presented with arterial hypertension persisting over a median period of 84 (5–240) months; 76.3 per cent of the patients had previously been treated with an aldosterone antagonist, and 85 per cent with specific antihypertensives, whereas 52.6 per cent of all patients were under therapy with potassium compounds at the time of admission. After a median follow-up of 45 (7–114) months, potassium substitution was discontinued in 100 per cent of patients, and the aldosterone antagonist was discontinued in 94.7 per cent of patients. In 60.5 per cent of patients, the specific antihypertensive drugs were reduced. Patients with a reduction in antihypertensive medication had, compared with patients without a reduction, a shorter preoperative duration of arterial hypertension and a lower level of serum aldosterone, and were younger. Endoscopic adrenalectomy for Conn's syndrome leads to an immediate normalization of the electrolyte balance postoperatively, whereas hypertension resolves in 60.5 per cent of patients in the long-term course. Thus, the coexistence of essential hypertension or, respectively, a long duration of preoperative hypertension with associated renovascular alterations are of significance for the long-term result.

A comparison of transhiatal and transthoracic resections on the prognosis in patients with squamous cell carcinoma of the esophagus

AIM

The aim of this study was to investigate the long-term prognosis for squamous cell carcinoma of the esophagus treated either by the transhiatal (TH) or by the transthoracic (TT) operative approach.

PATIENTS AND METHODS

Two hundred and twenty-nine patients (median age: 56 (29-84) years) with squamous cell carcinoma of the esophagus underwent esophageal resection between September 1985 and April 2004. In 70 patients, the transhiatal approach and in 159, the transthoracic approach was applied. An extended mediastinal lymph-node dissection was only carried out in the course of the transthoracic technique.

RESULTS

Demographic data and tumor stages were comparable in both groups. A significantly better long-term survival was observed in patients with transthoracic approach for those who had undergone curative procedures (R0) (24 versus 13 months), as well as for those either without (pN0) (38 versus 14 months) or with lymph-node involvement (pN1), and for those with > or =16 (=median) dissected thoracic lymph nodes (25 versus 12 months) (p<0.05*). Patients with regional lymph-node involvement (pN1) were seen to have a significant prognostic advantage in cases with more than 16 (=median), rather than less than 16 mediastinal lymph nodes resected (p=0.045*).

CONCLUSION

The prognosis in patients with squamous cell carcinoma of the esophagus is influenced by the number of dissected mediastinal lymph nodes. Patients with regional lymph-node involvement appear to benefit from an extended lymphadenectomy, in spite of the higher rate of complications and mortality associated with this procedure.

[Minimally invasive adrenalectomy for pheochromocytoma: routine or risk?]

BACKGROUND

As a result of intraoperative catecholamine secretion with hemodynamic changes, larger tumor size, and marked neovascularization, adrenalectomy is more challenging and prone to complications for pheochromocytoma than for other adrenal diseases. The aim of this study was to examine the relative intraoperative risk of cardiovascular complications with the minimally invasive approach.

PATIENTS AND METHODS

Between February 1992 and May 2005, 82 operations were performed on 71 pheochromocytoma patients at our clinic. Of them, nine adrenalectomies were bilateral, one was trilateral, and two patients had recurrent procedures. Another five patients were included whose first operations took place before 1992. Thirty-six procedures were carried out conventionally (35 transperitoneally, one retroperitoneally) and 46 were endoscopic (28 transperitoneally, 18 retroperitoneally). There was no conversion to open procedure.

RESULTS

The median age at the time of surgery was 45 (24-75) years, and the median history of symptoms was 12 months (0-180). The openly resected pheochromocytomas were significantly larger than those in endoscopic operations: 5.5 cm (1-19 cm) vs 3.5 cm (0.5-8 cm) (P=0.0011). Compared with patients undergoing conventional procedures, those operated on endoscopically showed higher intraoperative systolic and diastolic blood pressures and peaks of more than 200 mmHg, although these differences were statistically insignificant. Multivariate analysis identified gender (P=0.0107), operative approach (P=0.0153), age (P=0.0364), and tumor size (P=0.0484) as factors with a possible influence on intraoperative hemodynamic alterations. Postoperative hospital stay was significantly shorter following endoscopic adrenalectomy (P=0.0001).

CONCLUSION

Endoscopic adrenalectomy for pheochromocytoma is suitable as a routine operation and harbors no increased risk of cardiovascular complications, making it the method of choice. The open procedure should be reserved for extraadrenal tumors or large tumors with the suspicion of malignancy.

Dissemination of hepatocellular carcinoma is mediated via chemokine receptor CXCR4

In different tumour entities, expression of the chemokine receptor 4 (CXCR4) has been linked to tumour dissemination and poor prognosis. Therefore, we evaluated, if the expression of CXCR4 exerts similar effects in human hepatocellular carcinoma (HCC). Expression analysis and functional assays were performed in vitro to elucidate the impact of CXCL12 on human hepatoma cells lines. In addition, expression of CXCR4 was evaluated in 39 patients with HCC semiquantitatively and correlated with both, tumour and patients characteristics. Human HCC and hepatoma cell lines displayed variable intensities of CXCR4 expression. Loss of p53 function did not impact on CXCR4 expression. Exposure to CXCL12 mediated a perinuclear translocation of CXCR4 in Huh7/Hep3B cells and increased the invasive potential of Huh7 cells. In HCC patients, CXCR4 expression significantly correlated with progressed local tumours (T-status; P=0.006), lymphatic metastasis (N-status; P=0.005) and distant dissemination (M-status; P=0.009), as well as with a decreased 3-year-survival rate (P=0.01). In summary, strong expression of CXCR4 is significantly associated with progressed hepatocellular cancer.