Is mesh pore size in polypropylene meshes associated with the outcome in Lichtenstein inguinal hernia repair: a registry-based analysis of 22,141 patients.

INTRODUCTION: Experimental data show that large-pored meshes reduce foreign body reaction, inflammation and scar bridging and thus improve mesh integration. However, clinical data on the effect of mesh porosity on the outcome of hernioplasty are limited. This study investigated the relation of pore size in polypropylene meshes to the outcome of Lichtenstein inguinal hernioplasty using data from the Herniamed registry. METHODS: This analysis of data from the Herniamed registry evaluated perioperative and 1-year follow-up outcomes in patients undergoing elective, primary, unilateral Lichtenstein inguinal hernia repair using polypropylene meshes. Patients operated with a non-polypropylene mesh or a polypropylene mesh with absorbable components were excluded. Polypropylene meshes with a pore size of 1.0 × 1.0 mm or less were defined as small-pored meshes, while a pore size of more than 1.0 × 1.0 mm was considered large-pored. Unadjusted analyses and multivariable analyses were performed to investigate the relation of pore size of polypropylene meshes, patient and surgical characteristics to the outcome parameters. RESULTS: Data from 22,141 patients were analyzed, of which 6853 (31%) were operated on with a small-pore polypropylene mesh and 15,288 (69%) with a large-pore polypropylene mesh. No association of mesh pore size with intraoperative, general or postoperative complications, recurrence rate or pain requiring treatment was found at 1-year follow-up. A lower risk of complication-related reoperation tended to be associated with small-pore size (p = 0.086). Furthermore, small-pore mesh repair was associated with a lower risk of pain at rest and pain on exertion at 1-year follow-up. CONCLUSION: The present study could not demonstrate an advantage of large-pore polypropylene meshes for the outcome of Lichtenstein inguinal hernioplasty.

[Effects of new minimum volume standards in visceral surgery on healthcare in Brandenburg, Germany, from the perspective of healthcare providers]. / Auswirkungen der neuen Mindestmengen in der Viszeralchirurgie auf die Gesundheitsversorgung in Brandenburg aus der Perspektive der Versorger:innen.

BACKGROUND: The legally prescribed minimum volume standards for complex esophageal and pancreatic surgery have been increased or will increase in 2023 and 2025, respectively. Hospitals not reaching the minimum volume standards are no longer allowed to perform these surgeries and are not entitled tor reimbursement. OBJECTIVE: The study aims to explore which effects are expected by healthcare professionals and patient representatives and what possible solutions exist for Brandenburg, a rural federal state in northeast Germany. MATERIAL AND METHODS: In this study 19 expert interviews were conducted with hospital employees (head/senior physicians, nursing director), resident physicians and patient representatives between July 2022 and January 2023. The data analysis was based on content analysis. RESULTS: Healthcare professionals and patient representatives expect a redistribution into a few clinics for surgical care (specialized centres); conversely more clinics that do not (no longer) perform the defined surgeries but could function as gatekeeping hospitals for basic care, diagnostics and follow-up (regional centres). The redistribution could also impact forms of treatment that are not directly defined within the regulation for minimum volume standards. The increased thresholds could also affect medical training and staff recruitment. A solution could be collaborations between different hospitals, which would have to be structurally promoted. CONCLUSION: The study showed that minimum volume standards not only influence the quality of outcomes and accessibility but also have a multitude of other effects. Particularly for rural regions, minimum volume standards are challenging for access to esophageal and pancreatic surgery as well as for communication between specialized and regional centres or resident providers.

Outcome of inguinal hernia repair after previous radical prostatectomy: a registry-based analysis with 12,465 patients.

INTRODUCTION: Following radical prostatectomy, the rate of inguinal hernias is fourfold higher compared to controls. Laparo-endoscopic repair after previous radical prostatectomy is considered complex. Therefore, the guidelines recommend open Lichtenstein repair. To date, there are limited data on inguinal hernia repair after prior prostatectomy. METHODS: In a retrospective analysis from the Herniamed Registry, the outcomes of 255,182 primary elective unilateral inguinal hernia repairs were compared with those of 12,465 patients with previous radical prostatectomy in relation to the surgical technique. Furthermore, the outcomes of laparo-endoscopic versus open Lichtenstein repair techniques in the 12,465 patients after previous radical prostatectomy were directly compared. RESULTS: Comparison of the perioperative complication rates for primary elective unilateral inguinal hernia repair with and without previous radical prostatectomy demonstrated for the laparo-endoscopic techniques significantly higher intraoperative complications (2.1% vs 0.9%; p < 0.001), postoperative complications (3.2% vs 1.9%; p < 0.001) and complication-related reoperations (1.1% vs 0.7%; p = 0.0442) to the disadvantage of previous prostatectomy. No significant differences were identified for Lichtenstein repair. Direct comparison of the laparo-endoscopic with the open Lichtenstein technique for inguinal hernia repair after previous radical prostatectomy revealed significantly more intraoperative complications for TEP and TAPP (2.1% vs 0.6%; p < 0.001), but more postoperative complications (4.8% vs 3.2%; p < 0.001) and complication-related reoperations (1.8% vs 1.1%; p = 0.003) for open Lichtenstein repair. CONCLUSION: Since there are no clear advantages for the laparo-endoscopic vs the open Lichtenstein technique in inguinal hernia repair after previous radical prostatectomy, the surgeon can opt for one or the other technique in accordance with their experience.

A significant vascular variant in oncologic pancreaticoduodenectomy: the arc of Buhler.

BACKGROUND: The arc of Buhler (AOB), a rare anastomosis connecting the superior mesenteric artery (SMA) to the celiac trunk (CA), was found in a patient suffering from an adenocarcinoma of the pancreatic head. CASE PRESENTATION: Oncologic pancreaticoduodenectomy required resection of the AOB to achieve complete tumor removal. After an uneventful clinical course in the first days, the patient suffered a severe complication. Due to ischemia of the stomach and spleen, complete resection of the stomach, spleen, and remaining pancreas had to be performed. CONCLUSIONS: The hemodynamic impact of this arterial variant has been discussed mainly for liver perfusion, which remained intact at all times in our case. Because of the serious obstacles mentioned above, we strongly recommend that the presence of AOB be considered in preoperative diagnosis and preservation when possible. If the AOB is likely to be ligated, stenosis of the SMA or CA should be excluded and resolved before surgery.

[Epidemiology and surgical treatment of pancreatic cancer in the State of Brandenburg : Analysis of 5418 cases]. / Epidemiologie und operative Behandlung des Pankreaskarzinoms im Flächenland Brandenburg : Analyse von 5418 Fällen.

BACKGROUND: Pancreatic cancer is the second most frequent cause of death among all forms of cancer in Germany with more than 19,000 deaths per year. The evaluation of the nationwide clinical cancer register aims to depict the reality of treatment and to improve the quality of treatment in the future by targeted analyses. METHOD: The data from the clinical cancer register of Brandenburg-Berlin for the diagnosis years 2001-2017 were analyzed with respect to the treatment of pancreatic cancer. Data from patients resident in the State of Brandenburg were evaluated with respect to epidemiological and therapeutic parameters. RESULTS: A total of 5418 patients with pancreatic cancer were documented in the register from 2001 to 2017 and 49.6% of the patients were diagnosed as having the Union for International Cancer Control (UICC) stage IV. A pancreas resection was carried out in 26.4% of the cases. In cases of cancer of the head of the pancreas the most frequent procedure was a pylorus-preserving resection with 51.8% and a pancreatectomy was carried out in 9.4%. The R0 resection rate of all pancreatic cancers in the period from 2014 to 2017 was 61.9%. After R0 resection the 5­year survival was 19%. Relevant multivariate survival factors were age, UICC stage and the residual (R) tumor classification. The case numbers per hospital had no influence on the absolute survival of patients operated on in the State of Brandenburg. CONCLUSION: The treatment reality in the State of Brandenburg for patients with pancreatic cancer corresponds to the results of international publications with respect to the key performance indicators investigated. A qualitative internationally comparable treatment of these patients is also possible in nonmetropolitan regions.

External Negative Pressure Drainage of the Pancreatic Duct in Pancreatogastrostomy Following Pylorus-Preserving Pancreaticoduodenectomy-Feasibility and Technique.

Background: Postoperative pancreatic fistula (POPF) is a major cause of morbidity after pancreaticoduodenectomy. There is no consensus on the best technique to protect the pancreato-enteric anastomosis and reduce the rate of POPF. This study investigated the feasibility and efficiency of external suction drainage of the pancreatic duct to improve the healing of pancreaticogastrostomy. Methods: Between July 2019 and June 2021, 21 consecutive patients undergoing elective pancreaticoduodenectomy were included. In all patients we performed a pancreaticogastrostomy and inserted a negative pressure drainage into the pancreatic duct. The length and diameter of the pancreatic duct were measured and the texture of the pancreas was evaluated. The daily secretion volume and the lipase value via pancreatic duct drainage were documented. The occurrence of POPF was evaluated. Results: None of the patients had drainage-related complications. In 4 patients we registered a dislocation of the drainage from the pancreas duct into the stomach. 17/21 Patients showed no signs of POPF. A biochemical leak was measured in one patient. Furthermore, 2 patients had a POPF grade B. In one patient, POPF grade C required reoperation and resection of the remnant pancreas. All 4 cases of POPF met the risk criteria soft pancreas, high volume and high lipase value in the duct drainage. Conclusion: The insertion of the pancreatic duct drainage was feasible and caused no drainage-related morbidity. POPF-rate was moderate in the risk population of soft pancreas and small duct.

Laparoscopic sphincter reconstruction after abdominoperineal resection: feasibility and technical aspects.

BACKGROUND: Abdominal colostomy has been reported as an option with good quality of life for patients requiring abdominoperineal resection (APR) for very low rectal cancer. Some young, compliant patients, nevertheless, are very motivated to avoid abdominal colostomy following APR. Spiral smooth muscle cuff perineal colostomy as neosphincter reconstruction can be a reasonable alternative. We have published before the results of a series of sphincter reconstruction in the conventional technique following APR. As we developed our technique for colorectal resection sphincter reconstruction, we also changed to a laparoscopic approach. The aim of the present study was to evaluate the feasibility of laparoscopic neosphincteric reconstruction and outline the aspects of the technique. METHODS: This retrospective study was conducted on 15 patients treated at our institution during a 6 year period for low rectal cancer by laparoscopic APR and spiral smooth muscle cuff perineal colostomy as sphincter reconstruction. At follow-up at a median time of 3.7 years (range 3-9 years) after surgery, patients underwent functional evaluation which included the modified Holschneider continence score (0-16), assessing consistency of stool, frequency, impulse, discrimination, warning period, incontinence for formed or fluid feces, soiling, wearing pads, drugs, enema where a score of 13-16 is associated with normal continence, as well as neosphincter manometry. RESULTS: Laparoscopic sphincter reconstruction was feasible in all 15 patients. Two of the fifteen patients (13%) required secondary colostomy in the long term due to neosphincter malfunction and neosphincter perforation after enema. Four of the remaining thirteen patients (30%) were partially continent according to the Holschneider continence score (HCS) with a score of 7-12. The other 9 (70%) were continent (HCS: 13-16). Neosphincter manometry showed a median resting pressure of 33 cm H2O (range 30-41 cm H2O) and a median squeeze pressure of 95 cm H2O (range 84-150 cm H2O). CONCLUSIONS: Laparoscopic sphincter reconstruction following APR is a feasible option offering an alternative to abdominal colostomy for selected patients.

[Risk factors for the development of lymphatic fistula after ilioinguinal lymph node dissection before isolated limb perfusion and its potential clinical relevance]. / Risikofaktoren für Lymphfisteln nach ilioinguinaler Lymphadenektomie im Rahmen einer isolierten Extremitätenperfusion und deren potenzielle klinische Relevanz.

INTRODUCTION: After ilioinguinal radical lymph node dissection (RLND), the therapy for lymph fistulas constitutes a challenge. Risk factors for the genesis of lymph fistulas have not been sufficiently evaluated. We investigated possible factors that could influence the development of lymph fistulas in patients suffering from malignant melanoma after iloinguinal RLND. PATIENT AND METHODS: The analysis was related to patients with intransit and lymphonodal metastasised malignant melanoma of the lower limb, who underwent RLND and isolated limb perfusion (ILP). Prospective data acquisition from patients undergoing ilioinguinal RLND and ILP in a one-step approach was performed. The association of lymph fistulas to risk factors was calculated using chi-squared, linear-by-linear test and ROC curves. As possible risk factors we investigated the presence of prior surgery and diabetes mellitus type II in the medical history, chemotherapeutics, patient age and the body mass index (BMI). RESULTS: Postoperative lymph fistula occurred in 11 of 108 patients (10.2%). A significant association to lymph fistulas was found in BMI (30.2± 7.0 kg/m (2), p<0.02). Other parameters, such as prior surgery (82% vs. 71%), diabetes mellitus type II (9% vs. 11.7%), chemotherapeutics and patient age (mean 67.8 vs. 62.4 years) showed no influence. CONCLUSION: Our results indicate that the incidence of lymph fistulas after RLND and ILP of malignant melanoma of the lower limb was associated with an increased BMI. Thus, for the prevention of lymph fistulae, an initially alternative wound-closure dressing like vacuum assisted closure (V.A.C.) dressing could be of clinical relevance for obese patients.

Treatment of oesophageal anastomotic leaks by temporary stenting with self-expanding plastic stents.

BACKGROUND: Oesophageal anastomotic leakage is associated with considerable morbidity and mortality. The aim of the present study was to assess the feasibility of using temporary self-expanding plastic stents to treat postoperative oesophageal leaks. METHODS: Patients with anastomotic leakage after abdominothoracic oesophagectomy treated by endoscopic insertion of self-expanding plastic stents between 2001 and 2007 were studied. Clinical outcomes were analysed, including healing of the leak, morbidity and mortality. RESULTS: Stents were inserted successfully in all 22 patients without procedure-related complications. Ten patients also required computed tomography-guided drainage because surgical drains had been removed. Non-ventilated patients received oral nutrition a mean of 4 days after stent placement. Combined treatment with stenting and drainage resulted in resolution of the leak in 21 of 22 patients. The mean healing time (time to stent removal) was 23 days. Stent migration occurred in five of 22 patients, but endoscopic reintervention with placement of a new stent was successful in all patients. Repeat thoracotomy with intraoperative stent placement was necessary in one patient with an oesophagocolonic anastomosis. One patient died in hospital. CONCLUSION: In combination with effective drainage, self-expanding plastic stents are an option for the treatment of oesophageal anastomotic leaks, and may reduce leak-related morbidity and mortality.

Loss of the coxsackie and adenovirus receptor contributes to gastric cancer progression.

Loss of the coxsackie and adenovirus receptor (CAR) has previously been observed in gastric cancer. The role of CAR in gastric cancer pathobiology, however, is unclear. We therefore analysed CAR in 196 R(0)-resected gastric adenocarcinomas and non-cancerous gastric mucosa samples using immunohistochemistry and immunofluorescence. Coxsackie and adenovirus receptor was found at the surface and foveolar epithelium of all non-neoplastic gastric mucosa samples (n=175), whereas only 56% of gastric cancer specimens showed CAR positivity (P<0.0001). Loss of CAR correlated significantly with decreased differentiation, increased infiltrative depths, presence of distant metastases, and was also associated with reduced carcinoma-specific survival. To clarify whether CAR impacts the tumorbiologic properties of gastric cancer, we subsequently determined the role of CAR in proliferation, migration, and invasion of gastric cancer cell lines by application of specific CAR siRNA or ectopic expression of a human full-length CAR cDNA. These experiments showed that RNAi-mediated CAR knock down resulted in increased proliferation, migration, and invasion of gastric cancer cell lines, whereas enforced ectopic CAR expression led to opposite effects. We conclude that the association of reduced presence of CAR in more severe disease states, together with our findings in gastric cancer cell lines, suggests that CAR functionally contributes to gastric cancer pathogenesis, showing features of a tumour suppressor.

Lymphatic mapping and sentinel lymph node biopsy in epidermoid carcinoma of the anal canal.

AIM: Although 15-25% of patients with anal cancer present with superficial inguinal lymph node metastases but the routine application of groin irradiation is controversial because of serious side effects. Inguinal sentinel lymph node biopsy (SLNB) can be used to select patients appropriately for inguinal radiation. The study evaluates the efficiency and clinical impact of SLNB. METHODS: Forty patients with anal cancer underwent 1 ml Tc(99m)-Nanocolloid injection in four sites around the tumour. Patients with inguinal radio colloid enrichment were selected for sentinel lymph node biopsy (SLNB). Lymph node status was examined by haematoxylin and eosin (H&E) as well as immunohistochemistry-staining. All SLN-positive patients were scheduled for inguinal radiation; SLN-negative patients with T1 and early T2 tumours were not scheduled for inguinal radiation. RESULTS: SLN were detected in 36/40 patients. Three common patterns of lymphatic drainage were observed: mesenterial, iliacal and inguinal. Twenty patients with inguinal SLN underwent SLN-biopsy. 6/20 patients were SLN-positive. In 10/20 patients SLNB altered the therapy plan--four patients with T1-tumours and positive SLN had additional groin irradiation, whereas 6 patients with small T2-tumors and tumour-free inguinal SLN did not undergo inguinal irradiation. CONCLUSIONS: Inguinal sentinel node biopsy in anal cancer is efficient and could assist in the decision for inguinal radiation. The validity and safety of the proposed therapeutic algorithm has to be proven by a larger, prospective study.

Markers of tumour angiogenesis and tumour cells in bone marrow in gastric cancer patients.

AIMS: Vascular endothelial growth factors VEGF-A, VEGF-C and VEGF-D are considered to be potentially angiogenetic and lymphangiogenetic. "Minimal residual disease" is responsible for cancer progression and recurrence. In this study, we investigated the relation between expressions of VEGF-A, VEGF-C and VEGF-D in gastric cancer tissue and the presence of tumour cells in bone marrow. METHODS: A total of 50 resected primary gastric adenocarcinomas, 44 non-cancerous gastric mucosa and 36 lymph node metastases were analyzed by immunohistochemistry for VEGF-A, VEGF-C and VEGF-D. The specimens used were drawn from a previous study cohort, where the presence of ITC in bone marrow was confirmed with immunohistochemical assay with cytokeratin (CK)-18. RESULTS: The levels of expression of VEGF-A, VEGF-C and VEGF-D were highest in tumour (p < 0.001), and the level in lymph node metastases was significantly higher (p < 0.01) than in mucosa. The expression of VEGF-A was correlated significantly with venous tumour invasion (p < 0.05) and the presence of tumour cells in bone marrow (p < 0.05). Tumours expressing high levels of VEGF-D showed significantly advanced stages of tumour infiltration (p < 0.05) and lymph node metastasis (p < 0.01). CONCLUSIONS: VEGF-A is a significant marker for the presence of tumour cells in the bone marrow of gastric cancer patients. Our results confirm VEGF-D as a predictor for the lymphatic spread of tumour cells. Therefore, the route of metastatic spread of gastric cancer could be determined, at least in part, by the profile of VEGF family members expressed in the primary tumour of gastric cancer patients.

Sentinel lymph node biopsy for gastrointestinal cancers.

Sentinel lymph node biopsy (SLNB) in gastrointestinal-(GI)-tract cancer is not yet of clinical relevance. Nevertheless, the results in the upper GI-tract promise to be helpful to individualize the indication for surgical therapy. SLNB in colon cancer still fails to show high validity to predict the nodal status, but may be helpful to clarify the prognostic role of micrometastases/isolated tumor cells. In anal cancer SLNB is able to guide the indication for groin irradiation.

Impact of patient- and disease-specific factors on SLNB in breast cancer patients. Are current guidelines justified?

BACKGROUND: The evidence on which to base guidelines for sentinel lymph node biopsy (SLNB) in breast cancer is still limited. In order to facilitate the further implementation of renewed guidelines, we evaluated patient- and disease-specific factors for their impact on the results of SLNB. MATERIALS AND METHODS: Prospective data acquisition from patients undergoing surgery for primary invasive breast cancer was performed. All patients underwent SLNB using the radiocolloid or the combined technique. The association of patient- and disease-specific factors to detection rate and false-negative rate was calculated using univariate and multivariate analyses (P < 0.05 considered as significant). Calculation of the false-negative rate was based on patients who underwent a backup axillary dissection. RESULTS: Among 455 consecutively enrolled patients, a significant inverse association to the detection rate was found for extracapsular extension of non-SLN metastases, body mass index (BMI), number of involved lymph nodes, pT category, tumor size, and age. A significant association to the false-negative rate to identify macrometastases was found for pT category, tumor size, and grading. Other factors, such as prior surgery, multicentric tumor growth, or vascular invasion, showed no influence. A cut-point analysis revealed that a tumor size of 2 cm separated the collective of patients with the highest significance in regard to the false-negative rate (9% vs. 25%). CONCLUSION: Our results indicate that SLNB can be safely used in elderly and obese patients with multicentric tumors and those having undergone prior surgery for benign breast disease. However, the method should be applied with caution in patients with tumors larger than 2 cm.

[Minimal residual tumor in gastrointestinal carcinoma. Relevance to prognosis and oncologic surgical consequences]. / Minimalresiduale Tumorerkrankung bei gastrointestinalen Karzinomen. Prognoserelevanz und onkologisch-chirurgische Konsequenzen.

Isolated tumor cells as a consequence of minimal residual disease are often not detectable by routine diagnostic procedures. However, before or after surgery, isolated tumor cells in lymph nodes, the peritoneal cavity, blood, or bone marrow can frequently be identified by immunohistochemical or molecular methods. Failure to reveal the presence of such cells results in under-staging of tumor patients and may constitute the source of unexpected tumor recurrence after radical surgery. These facts emphasize the importance of isolated tumor cells at least as a surrogate marker. The frequency of appearance of isolated tumor cells in different organ systems also depends on the type of primary tumor. Developments in modern detection methods have led to increasing sensitivity but at the expense of specificity. Isolated tumor cells demonstrate remarkable heterogeneity with respect to proliferative potential and tumorigenicity. This characteristic is also reflected by a striking variability in the expression of various genes conditioning the aforementioned biological behavior. Unfortunately there is also remarkable heterogeneity in methods used for sampling and processing patient material as well as for the enrichment and detection of isolated tumor cells. Despite the ongoing controversies concerning detection methods and biological significance of isolated tumor cells, several clinical trials providing data supporting the prognostic relevance of minimal residual disease should also be considered for gastrointestinal carcinoma. In future this finding should be integrated in the planning of trials in surgical oncology, and "minimal residual disease" should receive stronger attention as a stratification criterion in such clinical studies.

Surgical strategies for gastric cancer with synchronous peritoneal carcinomatosis.

BACKGROUND: Gastric cancer frequently spreads to the peritoneal cavity. Whether laparoscopy is useful in planning therapy remains controversial. The aim of this study was to investigate the value of laparoscopy and to develop a therapeutic algorithm. METHODS: Six hundred and sixty consecutive patients with gastric cancer were included in this prospective observational study. The sensitivity of abdominal ultrasonography, computed tomography (CT) and laparoscopy for detecting peritoneal carcinomatosis was compared. The lesions were biopsied and classified as P1, P2 or P3 according to the recommendations of the Japanese Research Society for Gastric Cancer. Prognosis was determined according to the stage of peritoneal carcinomatosis and therapeutic procedure adopted. RESULTS: One hundred and ten (16.7 per cent) of 660 patients presented with synchronous peritoneal carcinomatosis. The sensitivity for detecting peritoneal carcinomatosis was 85 per cent for laparoscopy compared with 19 per cent for ultrasonography and 28 per cent for CT. Patients with P3 disease did not benefit from additional surgery compared with chemotherapy alone. Those with P1 carcinomatosis had improved survival rates after complete resection followed by chemotherapy. CONCLUSION: Laparoscopy improves the detection and classification of peritoneal carcinomatosis, and offers patients with gastric cancer a more individualized and effective therapy.

Prediction of gastric cancer lymph node status by sentinel lymph node biopsy and the Maruyama computer model.

AIMS: The extent of lymph node dissection in gastric cancer remains controversial. The Maruyama computer model and the sentinel lymph node biopsy (SLNB) are compared for their value to predict the nodal status and lead to stage-adapted surgery. METHODS: Thirty four patients with stage I-IV gastric cancer underwent both staging procedures. For SLNB, 15 patients underwent endoscopic, peri-tumoural injection of (99m)Tc-colloid, and 19 patients were injected of Patent blue V. All 'hot' or blue sentinel lymph nodes (SLNs) were separately excised and histopathologically assessed. If the SLN was negative after routine staining by H&E, it was processed completely and reanalysed after immunohistochemistry. RESULTS: At least, one SLN was detected by means of SLNB in 33/34 of the patients. The sensitivity to identify a positive nodal status was 22/33 and the specificity/positive predictive value was 10/10 and 22/22. Additional micrometastases or isolated tumour cells in the SLN led to 'upstaging' of 5/15, initially classified as nodal negative by H&E-staining. Using the Maruyama computer model, a sensitivity of 22/23 for the correct prediction of the lymph node involvement was associated with a specificity of 2/10 and a positive predictive value of 22/30. CONCLUSIONS: The clinical impact of the Maruyama computer model is limited due to low specificity and a low positive predictive value, rendering the method less useful as an indicator for individualised surgery.

[Optimization of staging in colon cancer using sentinel lymph node biopsy]. / Optimierung des Staging beim Kolonkarzinom durch Sentinel-Lymphknoten-Biopsie. Aktuelle Aspekte.

Routine determination of the nodal status in colon cancer is strongly dependent on the individual quality and technique of histopathological assessment and surgical lymph node dissection. We evaluated whether sentinel lymph node biopsy (SLNB) could contribute to an improvement in staging. At least one SLN (median n=2) was detected (detection rate 84%) in each of 38 of 45 patients with primary colon cancer. Ten of these 38 were found to have lymph node metastases by HE staining (26%), six of them in the SLN. Nine of the 28 patients that were initially nodal-negative by HE revealed one micrometastasis and eight cases of isolated tumor cells by immunohistochemical (IHC) staining (32% upstaging response). Including the IHC-positive cases, 19 of the 38 patients were nodal-positive (50%), 15 of them with tumor-infiltrated SLN (overall sensitivity of SLNB 79%). Using the dye method, SLNB is clinically practicable and leads in the majority of the patients to the detection of SLN. The selective, intensified histopathological assessment of SLN identifies small tumor cell deposits in a relevant percentage of patients with little and clinically practicable effort.

[Sentinel lymph node biopsy in colorectal carcinoma]. / Sentinel Lymph Node beim kolorektalen Karzinom.

Lymph node status as an important prognostic factor in colon and rectal cancer is affected by the selection and number of lymph nodes examined and by the quality of histopathological assessment. The multitude of influences is accompanied by an elevated risk of quality alterations. Sentinel lymph node biopsy (SLNB) is currently under investigation for its value in improving determination of the nodal status. Worldwide, the data of 800 to 1000 patients from about 20 relatively small studies are available that focus rather on colon than rectal cancer patients. SLNB may be of clinical value for the collective of patients that are initially node-negative after H&E staining but reveal small micrometastases or isolated tumor cells in the SLN after intensified histopathological workup. If further studies confirm that these patients benefit from adjuvant therapy, the method may have an important effect on the therapy and prognosis of colon cancer patients as well. Another potential application could be the determination of the nodal status after endoscopic excision of early cancer to avoid bowel resection and lymphonodectomy.