Lernziele im Querschnittsbereich Rehabilitation, Physikalische Medizin und Naturheilverfahren nach der 9. Revision der Approbationsordnung für Ärzte

In October 2003 the 9 (th) revision of the Federal Medical Training Regulations (Approbationsordnung) came into effect. The new compulsory interdisciplinary subject "Rehabilitation, Physical Medicine, Naturopathic Treatment" offers the opportunity to teach all students in comprehensive concepts of Rehabilitation such as the International Classification of Functioning, Disability and Health (ICF) of the WHO and the new book 9 of the German Social Code (SGB 9), as well as Physical Medicine and Naturopathic Treatment. Since the content of this new subject has not been defined up to date a joint task force of the German Society of Rehabilitation Science and the German Society of Physical Medicine and Rehabilitation was founded in order to recommend teaching standards. As part of these teaching standards educational objectives are introduced in this article. They should guide the persons in charge of teaching the subject in the medical faculties. In some areas the students should acquire profound abilities and skills in addition to knowledge. The medical faculties may focus on different educational targets according to their individual teaching profile.

Matched pair analysis of survival after chest-wall recurrence compared to mammary recurrence: a long-term follow up

BACKGROUND

Local recurrence remains a major concern after primary treatment of breast cancer and has a major impact on subsequent survival. While most studies report a poorer survival rate in patients with a local recurrence after mastectomy than after breast conservation, it remains controversial whether different risk profiles at the time of primary diagnosis may account for this difference.

METHOD

Matched pair analysis of 134 patients with newly diagnosed locoregional recurrence of breast cancer without evidence of systemic disease. Matching criteria included the primary surgical treatment, tumor size, nodal status, and age. The significance of various prognostic parameters at the time of primary diagnosis and at the time of recurrence were evaluated, by univariate and multivariate analyses, with respect to survival after recurrence. The median follow-up was 8.4 years.

RESULTS

Risk factors at the time of presentation, such as tumor size and lymph node status, were comparable between both groups. Local recurrence occurred on an average 9 months earlier in patients after mastectomy (P = 0.08). Univariate analysis showed that lymph node status (P = 0.0001) and disease-free interval from primary treatment to local recurrence (P = 0.0002) were the most significant single prognostic factors for subsequent survival after local recurrence. The primary surgical treatment modality was shown to be of marginal statistical influence (only P = 0.05).

CONCLUSION

Local recurrence after mastectomy seems to be associated with worse survival than after breast-conserving therapy. Early onset of chest-wall recurrence, moreover, represents the highest independent risk for cancer-associated death.

Radiotherapy of the chest wall following mastectomy for early-stage breast cancer: impact on local recurrence and overall survival

INTRODUCTION

Recent studies have renewed an old controversy about the efficacy of adjuvant radiotherapy following mastectomy for breast cancer. Radiotherapy is usually recommended for advanced disease, but whether or not to use it in pT1-T2 pN0 situations is still being debated. This study was designed to clarify whether or not routine radiotherapy of the chest wall following mastectomy reduces the risk of local recurrence and if it influences the overall survival rate.

METHODS

Retrospective analysis of patients treated with mastectomy for pT1-T2 pN0 tumors and no systemic treatment. Patients treated with radiotherapy of the chest wall following mastectomy (Group A) are compared with those treated with mastectomy alone (Group B).

RESULTS

A total of 918 patients underwent mastectomy. Patients who received adjuvant radiotherapy after mastectomy (n = 114) had a significantly lower risk for local recurrence. Ten years after the primary diagnosis, 98.1% of the patients with radiotherapy were disease free compared to 86.4% of the patients without radiotherapy. The average time interval from primary diagnosis until local recurrence was 8.9 years in Group A and 2.8 years in Group B. The Cox regression analysis including radiotherapy, tumor size and tumor grading found the highest risk for local recurrence for patients without radiotherapy (p < 0.0004). In terms of overall survival however, the Kaplan-Meier analysis showed no difference between the two groups (p = 0.8787) and the Cox regression analysis failed to show any impact on overall survival.

CONCLUSION

With observation spanning over 35 years, this study shows that adjuvant radiotherapy of the chest wall following mastectomy reduces the risk for local recurrence in node-negative patients with pT1-T2 tumors but has no impact on the overall survival rate.

Tumor proliferation in squamous cell carcinoma of the vulva

Tumor proliferation is of important prognostic significance for several neoplasms. The very few previous studies on this parameter in vulvar carcinoma have shown contradictory results. The aim of this study was to determine the prognostic significance of tumor proliferation in vulvar carcinoma. Paraffin-embedded tissue of 74 squamous cell carcinomas of the vulva was immunostained for MIB-1, detecting Ki-67, and analyzed for staining patterns and the percentage of positive cells. There were three general staining patterns: a diffuse distribution (diffuse type), a localized staining at the infiltrating tumor border (infiltrating type), and a localized staining in basal parts of infiltrating tumor cell aggregates (basal type). The percentage of positive cells was not correlated with morphologic or clinical parameters, nor was it correlated with disease-free and overall survival. MIB-1 staining types were correlated with tumor type and grading. Tumors of diffuse and infiltrating type seemed to have more frequent lymph node metastasis (p = 0.053) and shorter disease-free survival (p = 0.076). In these tumors, overall survival time was reduced significantly (p = 0.02). In multivariate analysis, MIB-1 staining types were the most important factor for overall survival with an odds ratio of 4.73. In conclusion, distribution and not the percentage of proliferating cells is of prognostic significance in squamous cell carcinoma of the vulva.

Prognostic relevance of immunohistology, tumor size and vascular space involvement in axillary node negative breast cancer

OBJECTIVE

Adjuvant treatment for patients with axillary node negative (ANN) breast cancer is controversial because operation alone gives a 70% cure rate. Features which predict recurrence are needed and we therefore evaluated the predictive value of tumor diameter and vascular involvement as well as of estrogen receptors (ER), progesterone receptors (PR), p53, MIB-1, c-erb and PCNA demonstrated by immunohistological staining in 178 patients with ANN breast cancer. Although ER status, tumor diameter and vascular space involvement were significantly correlated to the development of recurrence, their sensitivity, specificity and predictive value were too low to give them clinical value.

Accuracy of preoperative histology and macroscopic assessment of cervical involvement in endometrial carcinoma

OBJECTIVE

To compare the diagnostic accuracy between the preoperatively and macroscopically established determination of cervical involvement in endometrial carcinoma.

STUDY DESIGN

During the period 1987 to 1991, 154 patients with endometrial cancer were evaluated in a retrospective blind manner with the objective of assessing the diagnostic accuracy of the preoperative (prehysterectomy curettage) and the macroscopic (sectioned surgical specimen) determination of th involvement of the cervix. The results were compared with histological findings of the hysterectomy specimen (gold standard).

RESULTS

Preoperative pre-hysterectomy curettage established a sensitivity of 38% and a specificity of 91% whereas the macroscopic findings (gross appearance) confirmed a sensitivity of 50% and a specificity of 95%. A prevalence of 17% for cervical involvement was found. In patients with cervical involvement diagnosed on pre-hysterectomy curettage, a positive predictive value of 45% and negative predictive value of 88% were established. A positive predictive value of 68% and a negative predictive value of 90% resulted from the judgement of the cervical gross appearance.

CONCLUSIONS

We conclude that the cervical involvement of endometrial carcinoma diagnosed on pre-hysterectomy tissue is less predictive than the judgement of the intraoperative gross appearance of the cervix.

A chondroitin/dermatan sulfate form of CD44 is a receptor for collagen XIV (undulin)

Collagen XIV, a fibril-associated collagen with interrupted triple helices, is expressed in differentiated soft connective tissues and in cartilage. However, a cellular receptor for this protein has not been identified. Here we show that human placental collagen XIV, isolated by a mild and simple two-step method, serves as adhesive protein for a variety of mesenchymal and some epithelial cells. Cell adhesion could be inhibited by preincubation of the collagen XIV substrate with heparin or with the chondroitin/dermatan sulfate proteoglycan decorin and by pretreatment of cells with chondroitinase ABC or heparinase III, suggesting a cell membrane proteoglycan as receptor. Affinity chromatography of 125I-labeled fibroblast cell surface proteins on collagen XIV-Sepharose yielded a chondroitin/dermatan sulfate proteoglycan with a molecular mass of 97-105 kDa after chondroitinase ABC digestion and of 60-70 kDa after further treatment with N-glycosidase F. The eluates contained also some high-molecular-weight material that was susceptible to digestion with heparinase but no detectable integrins. Immunoprecipitation with a specific monoclonal antibody identified the prominent chondroitin/dermatan sulfate proteoglycan as a member of the CD44 family. The interaction between collagen XIV and cells appears to be finely tuned, since matrix-associated glycosaminoglycans, and particularly proteoglycans like decorin, could compete with cells for the binding site(s) on collagen XIV under physiological conditions.

Prognostic factors of early stage cervical cancer treated by radical hysterectomy

BACKGROUND

This study was performed to identify pathologic and clinical features that best correlate with lymph node metastasis and disease free survival among patients with Stage I and II cervical cancer treated by radical hysterectomy.

METHODS

Three hundred-seventy patients with complete clinical information and pathologic material, including cone and cervical biopsies, were selected for analysis. Of these patients, 301 with clinical stages I and II disease were the subject of this paper. The results of patients with microinvasive carcinoma of the cervix, as defined by the Society of Gynecologic Oncologists (depth of invasion < or = 3 mm and no lymph node vascular space invasion), were reported previously and excluded from this analysis. Patients with small cell carcinoma of the cervix were found to have a very poor prognosis (disease free 5-year survival of 36%) and were also excluded from this analysis (Sevin BU, Nadji M, Metkoch MW, Lu Y, Averette HE. Unpublished data, 1995). Variables studied were patient age, weight, race, marital status, and economic status; tumor size; depth of invasion; lymph node-vascular space involvement; cell type; tumor grade; lymph node metastasis; and number of lymph nodes removed. The influence of these variables on survival was examined by univariate analysis with use of Cox's regression model and the log rank test for comparison of survival curves.

RESULTS

Factors that predict disease free survival, ranked by degree of significance, were depth of invasion, tumor size, lymph node-vascular space invasion, number of positive nodes, tumor volume, clinical stage, and tumor extension to the vagina or surgical margins.

CONCLUSIONS

Radical hysterectomy and bilateral lymphadenectomy is standard therapy for patients with Stage IB and IIA carcinoma of the cervix. A variety of surgically defined risk factors predict 5-year disease free survival, and many of these factors are related. Identification of independent risk factors requires a multivariate analysis of data.

Reliability of tumor typing of endometrial carcinoma in prehysterectomy curettage

The aim of this study was to determine the sensitivity and the specificity of tumor typing in the prehysterectomy curettage in order to assess the diagnostic accuracy in patients with endometrial cancer. Tumor typing was performed on complete prehysterectomy curettages of 154 patients with endometrial cancer treated during 1987-1991. The results were compared with the histologic findings of the hysterectomy specimen as the gold standard. Patients with no carcinoma demonstrable postoperatively in the removed uterus were excluded from the study. Tumor typing on prehysterectomy curettage revealed only a moderate sensitivity of 46-64%. In contrast, the specificity was > 90% for all histologic subtypes with the exception of the endometrioid tumor type (68%). The histologic subtypes (papillary, adenocarcinoma with squamous differentiation, mucinous, serous papillary, clear cell) achieved similar high predictive values despite a much lower prevalence due to the high values of specificity. Tumor typing of endometrial carcinoma based upon the findings of the prehysterectomy curettage reveals different reliabilities depending on the tumor type.

Prognostic factors that predict pelvic lymph node metastasis from endometrial carcinoma

BACKGROUND

Recent reports indicate that certain pre- and intraoperatively determined risk factors are predictive of pelvic lymph node metastases from endometrial cancer, allowing selective pelvic lymph node dissection. The objective of this study was to evaluate the accuracy of pre-, pre-/intra- and postoperatively determined tumor characteristics.

METHODS

The study is based on 100 patients treated from 1987-1991 with total abdominal hysterectomy and bilateral salpingo-oophorectomy. In all patients thorough pelvic lymphadenectomies were performed (no sampling). These patients were evaluated according to different macroscopic and histologic tumor characteristics retrospectively in a blind fashion (the lymph node status was later determined separately). Multivariate analysis was applied and the results were compared using receiver operator characteristic curves. In 15 of 100 patients, pelvic lymph node metastases could be histologically demonstrated.

RESULTS

Multivariate analysis of 22 tumor characteristics identified the following as being independent in relation to pelvic lymph node metastases: preoperatively determined characteristics: serous papillary tumor type, invasion of myometrium, and histologic grade (Christopherson); pre-/intraoperatively: serous papillary type, histologic grade (Christopherson), and cervical involvement; and postoperatively: lymphangiosis carcinomatosa and hemangiosis carcinomatosa. Receiver operator characteristic curves show that for pelvic node metastases the postoperatively determined histologic findings are more predictive than all other factors that can be evaluated pre- and/or intraoperatively.

CONCLUSION

Pre- and intraoperative tumor characteristics can determine the individual risk for pelvic lymph node involvement, but additional studies addressing the therapeutic value of pelvic lymphadenectomy would be necessary to define a probability threshold for lymphadenectomy in a decision analysis.

[Neuroendocrine cancer of the uterine cervix: an especially aggressive form of cancer with clinical, diagnostic and therapeutic characteristics]

The compilation of neuroendocrine carcinomas of the cervix uteri comprises a rare group of carcinomas characterised by particularly aggressive behaviour. These carcinomas can be described and differentiated from similar carcinomas with different biological behaviour by light microscopy and immunohistochemical investigations. We present three patients with neuroendocrine carcinoma of the cervix, stage I b, all of them operated according to Wertheim's operation with pelvic lymphadenectomy and in one case paraaortal lymphadenectomy. In all three cases we found a clinical manifestation of hematogenic metastases. Since we are not aware of any reports on this form of carcinoma in German literature, we would emphasise the importance of diagnostic differentiation between neuroendocrine carcinomas of the cervix and other similar carcinomas of this localisation, in particular since this form of carcinoma requires specific therapeutic procedures.

[Adenocarcinoma and adenosis of the vagina. On the histogenesis, diagnosis and therapy of a rare genital neoplasms]

In the United States, vaginal adenosis and clear-cell carcinoma of the vagina were frequently observed in young women, who had been exposed to the synthetic estrogen diethyl-stilbestrol (DES) during their embryonic development. In Germany, obviously, no such exposure occurred. Clearly, such diseases also develop without the context of intrauterine exposure to certain substances. Our own case of such a partly exophytic, partly endophytic adeno-carcinoma of the vagina with multifocal vaginal adenosis, demonstrates the histogenesis, symptoms, diagnostic procedures and therapy of this rare disease. Since young women during their reproductive years are mostly affected, the possibility of fertility-conserving surgery is discussed despite the current practice of radical cancer surgery (with and without radiation). In the 25-year-old patient, we conducted a colpectomy whilst leaving the uterus and ovaries, and replaced the vaginal defect by a sigmoid transplant anastomosed to the cervix. The patient has regular menstrual cycles, should, however, not become pregnant for 1 to 2 years for oncological reasons.

Microinvasive carcinoma of the cervix

BACKGROUND

Microinvasive carcinoma of the cervix (MIC) has been poorly defined in the past and is still a focus of persistent controversy. In 1985, the International Federation of Gynecology and Obstetrics (FIGO) defined Stage IA as "preclinical invasive carcinoma, diagnosed by microscopy only," subdividing it into Stage IA1 or "minimal microscopic stromal invasion," and Stage IA2 or "tumor with invasive component 5 mm or less in depth taken from the base of the epithelium and 7 mm or less in horizontal spread." In 1974, the Society of Gynecologic Oncologists (SGO) defined MIC as any lesion with a depth of invasion of 3 mm or less from the base of the epithelium, without lymphatic or vascular space invasion.

METHODS

To assess the risk of lymph node metastasis and treatment failures, pathologic material and clinical data on 370 patients with Stage I carcinoma of the cervix, who were treated by radical hysterectomy and pelvic-aortic node dissection, were reviewed. Histopathologic analysis of tumors was based on a uniform format, including measurement of the maximum depth of invasion, the width and length of the horizontal tumor spread, invasive growth pattern, cell type, tumor grade, and lymphatic or vascular space involvement.

RESULTS

Of the 370 patients, 110 had a depth of invasion of 5 mm or less. Of these, 54 patients fulfilled the SGO definition of MIC; 42, the new FIGO Stage IA2 definition; and 27, both definitions. None of the patients with MIC, as defined by either the SGO or the new FIGO Stage IA2, had lymph node metastases or tumor recurrence. These data support the conclusion that MIC, defined by either the SGO or FIGO definitions, have a low risk for lymph node metastasis or recurrent carcinoma. A review of the literature indicated a recurrence rate for Stage IA2 of 4.2%. In addition to depth of invasion, lymph vascular space invasion is a better predictor of lymph node metastasis and recurrence than the surface dimension.

CONCLUSIONS

The authors recommend adoption of the SGO definition of MIC. Patients with a depth of invasion of 3 mm or less without lymph vascular space invasion safely can be treated conservatively.

Correlation of c-erbB-2 protein expression with histologic grade, lymph node involvement and steroid receptor status in human breast tumors

The association of c-erbB-2 gene amplification product (p185) with histologic tumor type in 100 patients with primary breast cancer was determined. In 49 patients with infiltrating ductal carcinoma p185 detection was correlated with histologic findings (tumor grade, lymphnode status, receptor status). Strong positive staining for p185 protein was found in 10 patients (20%) with infiltrating ductal breast carcinoma and correlated with complete negative estrogen/progesterone receptor status and with histologic grade G3. There was neither an association with lymphnode involvement nor was there any to negative estrogen and progesterone receptor status alone. At present, we cannot say whether or not there is a correlation between the degree of c-erbB-2 gene amplification and prognosis. Follow-up studies are necessary to determine whether c-erbB-2 gene amplification allows definition of a specific subset of women who could benefit from adjuvant therapy.

[Serous papillary adenocarcinoma of the endometrium]

7 cases of serous-papillary adenocarcinoma of the endometrium (UPSC) were found in a retrospective study of 80 patients which were treated at the Department of Gynaecology of the University of Munich from August 1987 to December 1989 because of endometrial adenocarcinoma. Characteristic histologic findings and prognostic factors of the UPSC were examined by means of large scale sections of the completely worked-up uteri and compared with the usual adenocarcinoma of the endometrioid type (UEC). Despite only minimal myometrial infiltration in some cases, lymphangiosis carcinomatosa was almost always present (6/7) and more than 50% of patients showed evidence of blood vessel involvement. In all patients with pelvic lymph node dissection metastases were found. According to our results in line with the literature, UPSC is a highly malignant and morphologically distinct variant of endometrial adenocarcinoma without promising treatment to date.

Vulvar Paget's disease. Is immunocytochemistry helpful in assessing the surgical margins?

From January 1977 to December 1988, 19 patients with biopsy-proven Paget's disease of the vulva underwent simple or radical vulvectomy at the University of Miami/Jackson Memorial Medical Center. All vulvectomy specimens were evaluated immunocytochemically for the expression of carcinoembryonic antigen (CEA), epithelial membrane antigen (EMA) and low-molecular-weight keratins 8 and 18 (LMK), both in areas containing neoplastic cells and in histologically negative surgical margins. Neoplastic Paget's cells stained positively for CEA in all cases; they were positive for EMA and LMK in 18 and 17 cases, respectively. In all eight cases with underlying in situ or invasive carcinomas, CEA, EMA and LMK were localized in the underlying tumors as well. None of the histologically proven negative margins reacted for CEA, EMA or LMK on immunocytochemistry. CEA appears to be a valuable immunocytochemical marker for extramammary Paget's disease; EMA and LMK are also expressed by the majority of such cases. None of these markers, however, is of added value in identifying Paget's cells in surgical margins if those margins appear negative on routine hematoxylin-and-eosin staining.