[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.

Permanent stoma after low anterior resection for rectal cancer

BACKGROUND AND OBJECTIVES

A low anterior resection procedure for removing a rectal tumor aims to preserve the sphincter and avoid a permanent stoma. Permanent stomas are primarily necessary in cases of poor anorectal function and local recurrence. The aim of this study was to clarify whether anastomosis-related complications and local recurrence influenced the rate of permanent stomas in a long-term follow-up.

METHODS

Of 1032 consecutive patients with rectal cancer, 397 were treated by low anterior resection (R0 and R1 resections) between 1985 and 2007 at the Department of General and Abdominal Surgery of the University Hospital, Mainz (Germany). All patient data were collected prospectively. A retrospective, multivariate analysis was conducted to determine factors that influenced the occurrence of delayed and nonreversal of defunctioning stoma, the rate of repeat stoma after closure, and the need for a permanent stoma in patients whose stomas were not initially defunctioning.

RESULTS

A defunctioning stoma was created in 292 of 397 patients (74%); 12% of stomas were not reversible (33/279 that survived the operation >90 d); 11% (28/246) required a repeat stoma after stoma closure; 10% (10/105) of patients whose stomas were not initially defunctioning received a late permanent stoma. The overall rate of a permanent stoma was 18%. The main reasons for a permanent stoma were anastomosis-related complications and local recurrence. Risk factors for anastomosis-related complication were male gender, low tumor site, and tumor stage. Despite a significant reduction in local recurrence rates from 1997 to 2007, the rate of creating a permanent stoma did not change.

CONCLUSIONS

The possibility of a permanent stoma should be considered when planning surgery for treating rectal cancer. It might be preferable in older patients, in poor condition and with more advanced rectal cancers, to consider an abdominoperineal resection or Hartmann procedure instead of a low anterior resection.

[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.

[Retroperitoneal sarcomas: diagnostic and therapy]

BACKGROUND

Due to the fact that there are no distinct anatomical compartments, retroperitoneal sarcomas are moreover diagnosed with evidence of large tumors and infiltration of adjacent organs. In spite of improvement of the diagnostic facilities and surgical techniques, quite frequently local recurrences with unfavourable prognosis turn up even after complete removal. It was the aim of this study to analyze diagnosis, therapy and long-term prognosis in patients with retroperitoneal sarcomas over a period of 10 years.

PATIENTS AND METHODS

Between January 1995 and January 2005, 379 patients underwent surgery for a primary retroperitoneal tumor at our clinic. Among the 67 (17.1 %) malignant lesions, a sarcoma was found in 35 patients. The present study is focused on the long-term prognosis of those 21 patients with a primary resected retroperitoneal sarcoma, recurrent sarcomas and exploratory laparotomies excluded.

RESULTS

The median patient age at the time of surgery was 61 (25-86) years, 57.1 % were males. The duration of symptoms was 3 (1-36) months. A pR0-resection was achieved in 20/21 patients. Among the histopathological tumor types, liposarcomas (n = 10) and leiomyosarcomas (n = 6) were found most frequently. Local recurrence developed in 12 out of 21 patients at 13.5 (5-42) months after the first operation, and in 4 patients distant metastases were observed. The long-term survival of all 21 patients with primary resected retroperitoneal sarcoma was 24 (1-101) months. A more favourable prognosis was seen in patients with leiomyosarcoma as compared with liposarcoma.

CONCLUSION

Retroperitoneal sarcomas are a heterogeneous entity, and they were found among our own patients in 6.1 % of all primary operatively treated retroperitoneal tumors. The strategy of treatment is complex and dependent on the stage, localization and histopathological characteristics. Long-term survival is limited as a result of the high rate of local recurrence.

Effect of chemokine receptors CXCR4 and CCR7 on the metastatic behavior of human colorectal cancer

PURPOSE

The expression of chemokine receptors CXCR4 and CCR7 has been associated with tumor dissemination and poor prognosis in a limited number of tumor entities. However, no data are currently available on the impact of chemokine receptor expression on disease progression and prognosis in human colorectal cancer.

EXPERIMENTAL DESIGN

The expression of CXCR4 and CCR7 was evaluated in 96 patients with histologically confirmed colorectal cancers and in four colorectal cancer cell lines by immunohistochemical staining. Furthermore, cell migration assays were done with SW480, SW620, and LS174T cancer cells to confirm the effect of the CXCR4 ligand stromal cell-derived factor 1alpha on migration.

RESULTS

Human colorectal cancer specimens and cell lines displayed a CXCR4 and CCR7 expression with variable intensities. Interestingly, strong expression of CXCR4, but not of CCR7, was significantly associated with higher Union International Contre Cancer stages 3/4 (P = 0.0017), lymph node metastasis (P = 0.00375), and distant metastasis (P = 0.00003) and further correlated with a reduced 3-year survival rate (P = 0.1). Strong CXCR4 and CCR7 expression positively correlated with the location of the primary tumor in the rectum (P < 0.01). Furthermore, activation of CXCR4-expressing cancer cells by stromal cell-derived factor 1alpha resulted in a significant increase of cell migration (P < 0.014).

CONCLUSION

Strong expression of CXCR4 by colorectal cancer cells is significantly associated with lymphatic and distant dissemination in patients with colorectal cancer as well as with cancer cell migration in vitro.

Subtotal or total gastrectomy for gastric cancer: impact of the surgical procedure on morbidity and prognosis--analysis of a 10-year experience

BACKGROUND

Against the background of the continuing controversy as to the surgical procedure of choice for gastric cancer, the aim of the present study was to evaluate perioperative morbidity, prognostic factors of survival, and long-term survival after subtotal, abdominal and abdominothoracic gastrectomy in patients with gastric cancer.

PATIENTS AND METHODS

Between January 1993 and December 2002, 338 consecutive patients underwent surgery for adenocarcinoma of the stomach. Subtotal gastrectomy was carried out in 80 (23.7%) patients; 240 (71.0%) patients had abdominal gastrectomy, and 18 (5.3%) underwent abdominothoracic gastrectomy.

RESULTS

At an overall 30-day mortality of 3.6% (hospital mortality, 5.2%), the total complication rate was 16.3%. The estimated 5-year survival rate was 43% in patients after subtotal gastrectomy, 39% in patients with abdominal gastrectomy, and 28% in patients with abdominothoracic gastrectomy after complete tumour clearance, without significant differences between the groups. Patients who underwent left pancreatectomy and had a higher ratio of metastatic/dissected lymph nodes were characterised by a significantly poorer prognosis.

CONCLUSION

The lower morbidity and mortality rate with a nearly identical long-term survival yielded by subtotal gastrectomy compared with total gastrectomy leads us to justify subtotal gastrectomy, especially in elderly patients with comorbidity and a high operative risk, on the condition that its performance is radical from an oncological point of view.

Prognostic factors following liver resection for hepatic metastases from colorectal cancer

BACKGROUND/AIMS

We aimed to identify prognostic factors that may allow better patient selection for liver resection for colorectal liver metastases.

METHODOLOGY

A retrospective analysis of the files of 120 patients undergoing liver resection for colorectal metastases between 9/85 and 12/96 was performed. Survival and disease-free survival were calculated, and a uni- and multivariate analysis for the prognostic impact of various perioperative factors on survival was performed.

RESULTS

Perioperative morbidity and mortality were 28.3% and 5.8% respectively. Median overall survival was 30 months with a 5-year survival rate of 31%. Radicality was the prime prognostic determinant. In patients with R0-resection, a liver metastasis of > 3.5 cm in diameter was the only independent factor associated with an adverse prognosis.

CONCLUSIONS

Liver resection for colorectal liver metastases should be attempted if complete resection with clear margins is feasible and may be especially beneficial in patients with small (< or = 3.5 cm) lesions.

Liver resection for breast cancer metastases

BACKGROUND/AIMS

The prognosis of patients with hepatic metastases (HM) from breast cancer receiving no treatment is extremely poor. Results of systemic and regional chemotherapy as well as other treatment modalities, such as immunotherapy or hormonal therapy, are disappointing in this group of patients, with median survival rates hardly exceeding 1 year.

METHODOLOGY

We performed a retrospective analysis of patients undergoing resection of isolated HM from breast cancer to determine the morbidity, mortality and prognosis following this procedure.

RESULTS

Fifteen female patients underwent liver resection between September 1985 and April 1997. Two patients had synchronous and 13 patients had metachronous HM. The mean number of HM was 3.3 (1-9) (bilobar in 6 patients) with a mean diameter of 5.3 cm (2-11 cm). The following resections were performed: wedge resection (4), left lateral segmentectomy (2), right hemihepatectomy (3), left hemihepatectomy (1), extended right hemihepatectomy (3) and extended left hemihepatectomy (2). There was no hospital mortality. Morbidity (transient hepatic failure (n=2) and intra-operative hemorrhage necessitating splenectomy (n=1)) occurred in 3 patients. Median follow-up was 12 (1-88) months. Six patients developed recurrent liver disease; 2 relapsed elsewhere. Six of these 8 patients died. Overall median survival following liver resection was 57 months with 1-, 2- and 3-year survival rates of 100%, 71.4% and 53.6% respectively.

CONCLUSIONS

Liver resection is a viable treatment option for selected patients with isolated HM from breast cancer that can be performed safely. It should be considered in individual patients if the operative risk is low, if no extrahepatic disease is present and provided a complete resection with clear margins is technically feasible.

[Breast cancer screening in surgical patients]

Between January and August 1996, 304 patients of the Department of General and Abdominal Surgery of the University of Mainz who were at least 40 year old, were interviewed about their breast cancer screening behavior. The aim of our investigation was to evaluate the attitude of the target population to breast screening and the value of breast palpation, completed with mammography, during the women's treatment in hospital. 168 (55%) of the interviewed women reported that they had a yearly clinical breast examination in the past. All patients underwent a clinical breast examination. 185 (60%) did not have a mammography in the past or within the past 2 years. These women were offered a mammographic examination during their treatment in the hospital. The investigation revealed one invasive breast cancer. 13 patients had abnormal mammographic or sonographic findings. Our investigation shows, that the compliance of the target population for breast cancer screening is low. Therefore it is necessary to point out the value of breast cancer prevention with clinical examination and mammography also for patients treated in the hospital for an other disease. Every female patient should undergo breast examination. But early detection of breast cancer before micrometastases have occurred is only possible by mammography.