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.

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.

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)]. / Qualitätsindikaktoren der Diagnose und Therapie bei MRT-basierter neoadjuvanter Radiochemotherapie des Rektumkarzinoms - Interimsanalyse einer prospektiven, multizentrischen Beobachtungsstudie (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.

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.

[Palliative care for patients with oesophageal cancer]. / Palliativtherapie beim Ösophaguskarzinom.

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]. / Das Optimult-Studienkonzept - Grundlage für selektiven Einsatz neoadjuvanter Radiochemotherapie auf MRT-Basis?

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.

[Diagnosis of and therapy for gastric cancer--work-flow]. / Diagnostik und Therapie des Magenkarzinoms--Workflow.

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.

Malignant and unclear histological findings in incidentalomas.

BACKGROUND: The management of incidentalomas with tumor size 3 cm and larger is still under controversial discussion. STUDY DESIGN: Clinical charts of 65 patients who underwent adrenalectomy for an incidentaloma were reviewed. RESULTS: Sixty-five patients were operated. There were 28 men and 37 women with a median age of 56.9 years. Median size of all resected lesions was 4.1 cm. Indications for surgery were tumor size equal and larger than 3 cm, recurrent pain, hormone status and patients' fear of malignancy. In 45 patients, the adenomas did not meet the defined criteria of malignancy. There were 9 cases of adrenal hyperplasia, and two cysts and two hematomas were found in 4 patients. Moreover, 1 schwannoma and 1 myelolipoma were removed. In 3 patients, a primary adrenocortical carcinoma of 3.4, 4.0, and 5.0 cm in diameter, respectively, was identified. In 1 patient, an adrenal cortical carcinoma of 10.0 cm in diameter was operated. In 1 patient, the status (size: 4.5 cm) could not be determined conclusively. CONCLUSION: Hormonal activity should be determined independent of the size, and lesions with hormonal activity should be resected; in the presence of hormonally inactive masses, removal of tumors of 3 cm and larger in size is recommended.

[Problems in the treatment of upper rectal carcinoma]. / Probleme bei der Therapie des oberen Rektumkarzinoms.

In the literature there is some disagreement about the treatment of upper rectal carcinoma (aboral margin 12-16 cm from the anocutaneous line), in particular about the necessary extent of mesorectal excision and the indications for neoadjuvant and adjuvant therapy. The special pathologic features of upper rectal carcinomas (lymphatic spread, distal tumor spread beyond the gross margin) and present clinical experiences are discussed. From it result the following recommendations: partial mesorectal excision, neoadjuvant radiochemotherapy for cT4 tumors only; adjuvant radiochemotherapy in case of intraoperative tumor perforation or incision into/through tumor, incomplete partial mesorectal excision or tumor positive circumferential resection margin (CRM); adjuvant chemotherapy in case of histologically confirmed regional lymph node metastases.

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 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.

[Single center experience over a 5-year period with sequential transarterial chemoembolization (TACE) in the treatment of hepatocellular carcinoma (HCC)]. / Sequentielle transarterielle Chemoembolisation (TACE) des hepatozellulären Karzinoms (HCC)--Erfahrungsbericht eines einzelnen Zentrums über 5 Jahre.

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.

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.

[Appendicitis necessitatis: appendicitis perforating the abdominal wall]. / Appendicitis necessitatis: Durch die Bauchwand perforierte Appendizitis.

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.

[Nonerosive and erosive gastroesophageal reflux disease. Long-term results of laparoscopic anterior semifundoplication]. / Nichterosive und erosive gastroösohageale Refluxerkrankung. Langzeitergebnisse der laparoskopischen anterioren Semifundoplikatio.

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.

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.

Image cytometric DNA analysis of mucosal biopsies in patients with primary achalasia.

AIM: To determine DNA aneuploidy in mucosal biopsies of achalasia patients for subsequent rapid diagnosis. METHODS: Biopsies from the middle third of the esophagus were obtained in 15 patients with achalasia. Immunohistochemical staining was carried out with monoclonal antibodies MIB-1 for Ki67 and PAb 1801 for p53, in addition to the conventional histologic examination for dysplasia. Nuclei of fresh biopsy material were enzymatically and mechanically isolated, and the DNA content was determined with image cytometry after Feulgen staining. DNA grading of malignancy was assessed according to Boecking to determine the variability of DNA values noted around the normal diploid peak. Further indices measured included the aneuploid rate, and the 5c-, 7c- and 9c-exceeding rate. RESULTS: The histological examination did not demonstrate dysplasia; while MIB-1 (basal) showed a positive reaction in 8/15 achalasia specimens, p53 was negative in all specimens. Image cytometric DNA analysis detected aneuploidy in 4/15 (26.7%) specimens. Samples from 15 patients with squamous cell carcinoma as well as specimens obtained exclusively 2 cm proximal to the tumor served as reference tests. All carcinomas (15/15) as well as 9 of the peritumoral samples (9/15) were aneuploid. The comparison of biopsies from achalasia patients with peritumoral and carcinoma specimens revealed statistically significant differences regarding the aneuploid rate (diploid: P < 0.0001; tetraploid: P = 0.001), grading of malignancy according to Boecking (P < 0.0001) and the 5c- (P < 0.0001), 7c- (P < 0.0001), and 9c- (P = 0.0001) exceeding rate with progredient DNA alterations in the respective order. CONCLUSION: The finding that DNA aneuploidy was identified by image cytometry in esophageal specimens of patients with achalasia, which may be due to specific chromosomal alterations presenting as precancerous lesions in 27% of patients, leads us to conclude that image cytometry represents a valuable screening tool.

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

UNLABELLED: 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 N- and 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: FDG-PET 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.