Hepatic arterial Fotemustine chemotherapy in patients with liver metastases from cutaneous melanoma is as effective as in ocular melanoma

AIM

Hepatic metastases from melanoma are associated with poor prognosis. Systemic chemotherapy and biological treatments remain unsatisfactory. This study investigated the impact of hepatic arterial chemotherapy in patients with ocular and cutaneous melanoma.

METHODS

In a retrospectively analysed observational study, 36 consecutive patients with hepatic metastases from ocular or cutaneous melanoma were assigned for surgical hepatic port-catheter implantation. Fotemustine was delivered weekly for a 4-week period, followed by a 5-week rest and a maintenance period every 3 weeks until progression. Overall survival, response and toxicity were analysed and compared.

RESULTS

After port-catheter implantation 30/36 patients were finally treated (18 with ocular and 12 with cutaneous melanoma). A median of 8 infusions per patient were delivered (range 3-24). 30% thrombocytopenia grade >or=3, 7% neutropenia grade >or=3 but no nausea or vomiting grade >or=3 were encountered. Nine out of 30 patients achieved partial remission, 10/30 stable disease; 11/30 patients were progressive. Median survival for all treated patients was 14 months. Partial remission and stable disease were associated with a survival advantage compared to progressive disease (19 vs. 5 months). No significant difference in survival was observed for ocular versus cutaneous melanoma. Serum LDH was a significant predictor of both response and survival.

CONCLUSIONS

Hepatic arterial Fotemustine chemotherapy was well tolerated. Meaningful response and survival rates were achieved in ocular as well as cutaneous melanoma. Careful patient selection in consideration of extra-hepatic involvement is crucial for the effectiveness of this treatment. Independent from the primary melanoma site, it is debatable if patients with highly elevated serum-LDH may benefit from this approach.

Cytokeratin profiles identify diagnostic signatures in colorectal cancer using multiplex analysis of tissue microarrays

Background and aims: Recent cDNA expression profiling analyses indicate that within specific organ cancers Cytokeratins (CKs) dysregulation may identify subgroups with distinct biological phenotypes. Our objectives in this study were (1) to test whether cytokeratins were also distinct on the protein level, (2) to evaluate these biomarkers in a series of well-characterised CRCs, (3) to apply hierarchical cluster analysis to immunohistochemical data. Methods: Tissue microarrays (TMA) comprising 468 CRC specimens from 203 patients were constructed to evaluate CK5, CK7, CK8, CK13, CK14, CK16, CK17, CK18, CK19 and CK20. In total, 2919 samples were analyzed. Results: Unsupervised hierarchical clustering discovered subgroups represented by reduced CK8 and CK20 expression, that differed by a shorter patients survival. The evaluation of the specific biomarkers by Kaplan–Meier analysis showed that reduced CK8 expression (p < 0.01) was significantly associated with shorter patients’ survival, but was not an independent factor correlated with tumour stage (pT), grading (G) and nodal stage (pN). Conclusions: Reduced coexpression of CK8 and CK20 may indicate an epithelial-mesenchymal transition (EMT) representing an important step in the development of more aggressive CRCs. In addition, multiplex analysis of TMAs together with immunohistochemistry (IHC) supplemented by hierarchical clustering are a useful, promising and very powerful tool for the identification of tumour subgroups with diagnostic and prognostic signatures.

[Transcutaneous ultrasound]

Preoperative transcutaneous ultrasound allows surgeons to assess the pathology directly, thus supplementing clinical examination of the patient. Technical advances including power doppler, three-dimensional ultrasound, and the advent of ultrasound contrast agents have increased the quality and broadened the diagnostic spectrum of ultrasound. This article reviews relevant new aspects of transcutaneous ultrasound in the surgical setting.

[Abdominal vacuum device with open abdomen]

BACKGROUND

For the treatment of peritonitis or abdominal compartment syndrome, an open abdomen can be required. Because of the high complication rate associated with this method, different technical modifications were developed that are now being applied. Abdominal vacuum-assisted closure is increasingly favoured. We analyse our experience with this device in a distinct group of patients from gastrointestinal cancer surgery.

PATIENTS AND METHOD

From June 2003 to December 2005, 36 patients were treated with 151 double-layer abdominal vacuum devices. Indications for applying this device were peritonitis (n = 22), abdominal compartment syndrome (n = 11), and necrotising fasciitis (n = 3). Thirty-four patients gave anamneses of malignoma.

RESULTS

Overall, the vacuum therapy treatment lasted a median of 13 days (range 3-48). With it, four enteric fistulas (11%) and four abdominal wall bleedings (11%) occurred. In our patient group, no new intra-abdominal abscesses were observed. Four patients died during treatment with the vacuum-assisted device and four afterward because of multiple organ failure in acute sepsis (in-hospital mortality 22%). Twenty-six patients (72%) underwent direct fascial closure after a median treatment duration of 10 days. Six patients (17%) required synthetic mesh for fascial closure. After a median follow-up of 100 days, two patients developed ventral hernias and two others showed ossification of the scar.

CONCLUSION

Compared with other methods of temporary abdominal closure, our experience with the vacuum-assisted device demonstrates its advantages concerning clinical feasibility and the relatively low complication rate. The high rate of direct fascial closure with an acceptable rate of ventral hernias following vacuum-assisted abdominal closure are further benefits of this technique.

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.

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.

Resection of soft tissue sarcoma of the lower limb after evaluation of vascular invasion with intraoperative intravascular ultrasonography

Background

This study investigated the value of intravascular ultrasonography (IVUS) in the intraoperative assessment of vascular invasion of soft tissue sarcoma.

Methods

In a 4-year interval, of 337 patients with soft tissue sarcoma, 20 patients with tumours of the lower limb in close relation to the neurovascular bundle underwent intraoperative IVUS (20 MHz). Intraoperative findings were correlated with preoperative imaging, histopathological appearance of the resection specimen and patient outcome.

Results

Intraoperative IVUS was technically successful in all 20 patients. It correctly predicted vascular involvement (true positive) in ten of 11 patients who required resection of major vessels. There was one false-negative and one false-positive result. With magnetic resonance imaging, there were ten true-positive and three false-positive scans, and one false-negative diagnosis. IVUS improved the assessment of vascular involvement in four of the 20 patients. Histopathological examination confirmed complete resection (R0) in 18 patients. Mean survival was 37 months, and no local recurrence was observed in these patients.

Conclusion

Vascular infiltration by soft tissue sarcoma can be visualized accurately by IVUS. This may improve intraoperative decisions about vessel resection.

[Minimal residual tumor in gastrointestinal carcinoma. Relevance to prognosis and oncologic surgical consequences]

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.

Magnetic resonance-guided biopsy of suspicious breast lesions with a handheld vacuum biopsy device

PURPOSE

To evaluate a handheld vacuum-assisted device system for magnetic resonance image (MRI)-guided breast lesion biopsy.

MATERIAL AND METHODS

In 32 patients, a total of 42 suspicious breast lesions (mean diameter 7.5 mm for mass lesions, 11.6 mm for non-masslike diffuse lesions) seen with MRI (no suspicious changes in breast ultrasound or mammography) were biopsied (27 lateral, 15 medial) using a 10G vacuum-assisted breast biopsy device under MR guidance. Histology of biopsy specimens was compared with final histology after surgery or follow-up in benign lesions.

RESULTS

In all biopsies, technical success was achieved. Histology revealed 11 lesions with ductal carcinoma in situ (DCIS) or invasive cancer, three with intermediate lesions (LCIS) and 28 with benign breast lesions (adenosis, infected hematoma). In one patient with discordant results of MRI and histology, surgical excision revealed medullary cancer. In the follow-up (mean 18 months) of the histological benign lesions, no breast cancer development was observed. Besides minor complications (hematoma, n = 6), with no further therapeutic interventions, no complications occurred.

CONCLUSION

MRI-guided breast lesion biopsy using a handheld vacuum-assisted device is a safe and effective method for the work-up of suspicious lesions seen with breast MRI without changes in mammography or ultrasound. In the case of discordant histology of vacuum biopsy and breast MRI appearance, surgical excision is recommended.

Uptake, biodistribution, and time course of naked plasmid DNA trafficking after intratumoral in vivo jet injection

Nonviral jet injection is an applicable technology for in vivo gene transfer of naked DNA. However, little is known about the biodistribution and clearance of jet-injected DNA, or about its localization within tissue and cells. Therefore, in this study we analyzed the intratumoral and systemic biodistribution of jet-injected naked DNA in human colon carcinoma-bearing NCr-nu/nu mice, which were jet-injected with the pCMVbeta plasmid DNA. Intratumoral and systemic plasmid DNA biodistribution was analyzed 5, 10, 20, and 40 min and 3, 6, 24, 48, and 72 hr after jet injection, using quantitative real-time polymerase chain reaction. In the tumors, a rapid drop in naked DNA load within 24 hr of jet injection was shown. Detailed analysis of intratumoral distribution of rhodamine-labeled DNA revealed the presence of plasmid DNA within tumor cells 5 min after jet injection and further accumulation of significant DNA amounts in the cell nuclei 30 to 60 min after jet injection. In the blood, DNA amounts rapidly dropped within 10 to 40 min of jet injection to less than 0.001 pg of plasmid per 250 ng of tissue DNA and only minimal plasmid DNA dissemination was detected in liver, lung, spleen, kidney, and ovaries, which was cleared 3 to 6 hr after jet injection. By contrast, in heart, bone marrow, and brain almost no plasmid DNA was detectable.

[Efficacy of current adjuvant and neoadjuvant therapeutic concepts in gastric cancer?]

The incidence of gastric cancer in Europe is declining but the prognosis after curatively intended surgery remains dismal. In recent years several studies and meta-analysis concerning the impact of adjuvant postoperative chemotherapy and chemoradiation as well as preoperative chemotherapy were published. This review aims to interpret results and to support decision making in individual patients. Results of trials on adjuvant chemotherapy were inconsistent and the studies were underpowered to detect meaningful but modest advantages. Meta-analyses including more than 3 000 patients revealed a significant survival benefit but no specific chemotherapy protocol can be regarded an optimal regimen. Postoperative adjuvant schedules including cisplatin led to high drop out rates due to toxicity. Applying cisplatin and infusional fluorouracil initially after diagnosis as a so called neoadjuvant therapy is better tolerated. Two trials testing this approach showed a significant survival benefit with preoperative cisplatin and infusional fluorouracil as compared to surgery alone. Postoperative chemoradiation was shown to be effective concerning local regional relapses and survival benefit in a large trial in the US but the majority of patients were treated with less radical lymph node dissection than it is routine in Germany. Enrollment of patients in prospective trials evaluating the impact of adjuvant and neoadjuvant strategies is warranted.

Hat die palliative Resektion bei gastrointestinalen Tumoren noch einen Stellenwert?

Before any palliative tumor resection, the morbidity and mortality risks must be carefully weighed against the continued prognosis (including quick and lasting relief of discomfort from the tumor) and alternative strategies such as bypass, chemotherapy, and radiotherapy. Multimodal concepts have seen considerable progress in recent years, and endoscopic and interventional methods have expanded the instrumentarium for palliative tumor therapy. Thus the value of palliative resection must be reassessed. The most important criteria and study results are described here, as they have resulted in increased interest in palliative tumor resection within a multimodal treatment for most gastrointestinal tumors. More studies are needed to learn how much can realistically be expected of these new approaches.

Psychosozialer Betreuungsbedarf bei stationären Tumorpatienten

BACKGROUND

Patients with tumour disease are in particularly stressful situation at all times. The aim of the present study was to find what proportion of patients on a surgical oncology ward would also benefit from psycho-oncological care.

PATIENTS AND METHOD

Within a period of 6 months (IIIrd and IVth quarters of 2004) 406 of our tumour patients were questioned with the aid of a method (Po-Bado) developed specifically for use with such patients.

RESULTS

According to this inquiry, it can be assumed that 41.4% of tumour patients are in need of professional psycho-oncological support. Patients who are in hospital for diagnostic procedures to confirm or exclude the suspicion of tumour disease have a greater need for such support (48.7%) than do patients who have been admitted for a scheduled operation (37.3%). Correlations were found between the need for this therapy and different disease situations. The prevalence of need was highest among patients with a second tumour, in whom it was 66.7%. The type of tumour disease also had an influence whether psycho-oncological care was indicated. The study revealed that patients with malignant soft-tissue tumours (49%) and patients with tumours of the upper digestive organs (48.7%) find the mental stress more difficult to cope with than patients who are in hospital for treatment of malignant skin tumours (31.8%) or malignant tumours of the mammary gland (38.7%).

CONCLUSION

These results suggest that an adequate psycho-oncologic diagnostic at the start of a stationary stay are reasonable. This is a precondition for a well-directed psycho-oncologic intervention in order to enhance the disease accomplishment but at the same time the target-oriented supply of psycho-oncologic care in hospitals is a limited resource.

Registration of different phases of contrast-enhanced CT/MRI data for computer-assisted liver surgery planning: Evaluation of state-of-the-art methods

The exact localization of intrahepatic vessels in relation to a tumour is an important issue in oncological liver surgery. For computer-assisted preoperative planning of surgical procedures high quality vessel models are required. In this work we show how to generate such models on the basis of registered CT or MRI data at different phases of contrast agent propagation. We combine well-established intensity-based rigid and non-rigid registration approaches using Mutual Information as distance measure with different masking strategies as well as intensity inhomogeneity correction for MRI data. Non-rigid deformations are modelled by multilevel cubic B-splines. Quantitative evaluations of 5 MRI and 5 CT image pairs show that the liver moves rigidly 7.2 (+/- 4.2) mm on average, while the remaining non-rigid deformations range from 1.4-3 mm. As a result we find that masked rigid registration is necessary and in many cases also sufficient on clinical data. After non-rigid registration the matching shows no deviations in most cases.

CT-gesteuerte Resektion pulmonaler Metastasen

PURPOSE

To evaluate the feasibility and potential use of intraoperative computed tomography (IOP CT) as guidance for video-assisted thoracic surgery (VATS).

MATERIAL AND METHODS

Fifteen consecutive patients with peripheral intrapulmonary nodules underwent a thoracoscopy with IOP CT. Solitary lesions were known in 6/15 patients (40 %, group II) whereas 9/15 (60 %, group I) patients had multiple lesions (n >/= 2). IOP CT was performed with the mobile CT scanner Philips Tomoscan M. Radiologists intraoperatively placed percutaneous marks of lung lesions after unsuccessful VATS by use of a lung marker set (Somatex, Teltow, Germany). VATS was performed under general anaesthesia and with double lumen endotracheal intubation for single lung ventilation. Imaging quality and imaging of pulmonary nodules were rated.

RESULTS

IOP CT was evaluated as feasible combined with VATS. Thoracotomy was avoided in 5/15 patients where lesions could not be detected by VATS. A CT-guided biopsy was performed in two patients after an unsuccessful attempt of thoracoscopy. There were no documented side effects.

CONCLUSION

First clinical results suggest that a combination of VATS and IOP CT is feasible. Thus, the number of open thoracoscopies might be decreased. Intrapulmonary lesions not detectable with VATS could be marked under CT -- guidance intraoperatively and then resected by thoracoscopy.

[Optimization of staging in colon cancer using sentinel lymph node biopsy]

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.

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.

A coding mutation within the first exon of the human MD-2 gene results in decreased lipopolysaccharide-induced signaling

MD-2 is an accessory protein of the Toll-like receptor (TLR)-4, necessary for assembling a receptor complex to sense low quantities of lipopolysaccharide in order to subsequently trigger innate immune responses. MD-2 and TLR-4 are expressed on a variety of immunocompetent cells. Mutations within the TLR-4 gene have been shown to attenuate immune responses against lipopolysaccharide in mice. In humans, a TLR-4 polymorphism has been associated with a higher risk for developing severe Gram-negative sepsis and with a lower risk for atherosclerosis. Since MD-2 is an essential part of the lipopolysaccharide receptor complex, we screened 20 patients that underwent surgical cancer therapy for novel MD-2 mutations by a single-strand conformation polymorphism technique. In one patient we found an A --> G substitution at position 103, resulting in an amino-acid exchange from Thr 35 to Ala. Reporter gene assays revealed that this mutation resulted in a reduced lipopolysaccharide-induced signaling. The patient displayed an uneventful postoperative course, with the exception of slightly decreased TNF-alpha levels after in vitro stimulation with LPS as compared to wt patients. Genotyping of a further 41 patients by a newly developed Lightcycler/FRET method failed to detect any additional polymorphism carriers, indicating that this is a rare mutation.

VEMH - Virtual Euro-Mediterranean Hospital for Global Healthcare

The Virtual Euro-Mediterranean Hospital (VEMH) aims to facilitate the interconnection of various medical services through real integration. VEMH will provide an integrated satellite-terrestrial platform and realize telemedical services such as e-learning, real-time telemedicine and medical assistance and offer individual grants to young medical doctors. The methodologies of the VEMH are medical-need-oriented instead of technology-oriented. VEMH will provide for medical professionals in the whole Euro-Mediterranean area access to the required quality of medical service. For the successful deployment of the services of the VEMH GRID technologies have to be implemented especially for evidence-based medicine. A Metagrid Service Engine implements an additional software layer between proprietary GRID engines and the different applications. The use of mobile code is envisioned in future GRIDs which allows service creation and deployment on arbitrary nodes of a GRID. Dynamic Grid structures become an important point for the use of mobile code.

Weichteilsakrome

Soft tissue sarcomas are characterized by their heterogeneity. With new diagnostic imaging techniques, low- and high-grade components of the tumor can be differentiated. Thus biopsies should be guided by imaging to assure representative specimens. Besides histopathology, the advent of chromosomal and gene expression analysis may allow more accurate classification in the near future. Gene expression profiling has already proven its value by finding new subclassifications in other tumor types. Furthermore, this technique is a promissing tool to predict the response of a tumor to neoadjuvant and adjuvant therapy. Up to now, response evaluation in neoadjuvant therapy is based on tumor size and not on vital tumor cells. Newer techniques (i.e., Magnetic-resonance-Spectroscopy, Molecular Imaging) can show the change of metabolism in neoadjuvant therapy and allow objective, comparative measurement of biological activity. The diagnostic of soft tissue sarcomas implies primarily a multidisciplinary approach for a stage associated therapy.