Malignant intestinal non-Hodgkin's lymphoma from the surgical point of view

BACKGROUND

Primary intestinal non-Hodgkin's lymphoma (I-NHL) is much less frequent than gastric lymphoma and has hardly been studied in prospective trails. To the surgeon, patients frequently present with abdominal emergencies.

PATIENTS AND METHODS

A consecutive series of patients subjected to surgery because of I-NHL between 1998 and 1999 was evaluated retrospectively for characteristic clinical, radiographic and intraoperative findings. Patients with gastric lymphoma were not considered.

RESULTS

10 patients, 8 males and 2 females, with I-NHL were subjected to first-line surgery because of painful abdominal tumor, intestinal hemorrhage, obstruction or perforation. I-NHL was located most often in the small bowel (n = 7). It was rare in the colon (n = 2) and the duodenum (n = 1). Median postoperative follow-up was 28 months. Perioperative mortality was 10% (n = 1). Probability of survival 3 years after surgery was 60%.

CONCLUSIONS

Patients with I-NHL frequently present with complications of tumor growth, requiring urgent surgical treatment. Irrespective of surgical complications we advocate surgery in cases of resectable disease as first-line treatment. Adjuvant treatment is indicated with respect to resection status and histopathological staging.

[Diagnosis of pancreas tumors: MRI or multidetector spiral CT?]

Recent technical advances in the field of abdominal MRI and multi-detector spiral-CT (MSCT) have resulted in improved diagnostic capabilities of pancreatic tumors. Preliminary data demonstrate slight advantages of MRI in the detection of liver metastases and papillary tumors as well as in the differential diagnosis of pancreatic masses while MSCT might be advantageous in the assessment of vascular infiltration, particular in uncooperative patients.

Adjuvant radio-chemotherapy in stage II-III rectal cancer with 24-hour infusion of high-dose 5-fluorouracil and folinic acid: evaluation of feasibility

BACKGROUND

Postoperative radio-chemotherapy has been established as standard treatment for stage II and III rectal cancer patients in the last decade. To improve the efficacy of this therapy, we decided to evaluate continuous 24-hour infusion of 5-fluorouracil (5-FU) with folinic acid (FA) in combination with local radiation versus standard bolus 5-FU/FA with local radiation in a randomized study. Here we report on the first 28 patients to receive the experimental treatment.

PATIENTS AND METHODS

Patients with stage II and III rectal cancer received weekly 2-hour infusions of FA 500 mg/m2 followed by continuous 24-hour infusions of 5-FU 2,600 mg/m2 postoperatively via a Port-A-Cath system. The first cycle included 8 consecutive weekly administrations, the 1st-4th in full dose, the 5th-8th with 50% reduced dose while local irradiation (45 or 50.4 Gy) was performed. Thereafter, two further chemotherapy cycles (6 weekly administrations, 100% dose) followed.

RESULTS

28 patients received continuous 5-FU/FA treatment, of whom only 21 were evaluable for tolerability. 19 patients (90.4%) completed the first cycle, only 14 patients entered the second treatment cycle. Especially during the combined radiochemotherapy, increased toxicity was observed with grade III/IV diarrhea (n = 2), nausea (n = 1), leukopenia (n = 1), and cardiac toxicity (n = 1).

CONCLUSION

The high rate of premature treatment dropout indicate that the chosen schedule of weekly high-dose 5-FU/FA continuous infusion and combined postoperative radiotherapy should not be recommended for further use in postoperative adjuvant treatment.

Correlation of postoperative survival and angiogenic growth factors in pancreatic carcinoma

BACKGROUND/AIMS

VEGF (vascular endothelial growth factor) and EGF (epidermal growth factor) are promoters of angiogenesis. It was the aim of this study to investigate a possible coexpression of both growth factors in tumor samples of pancreatic cancer patients in relation to survival after resection of the tumor.

METHODOLOGY

We investigated the expression of VEGF165 and EGF in tumor specimen from 19 patients that underwent pancreaticoduodenectomy. Growth factor expression was determined using immunohistochemical methods.

RESULTS

Coexpression of VEGF165 and EGF was observed in tumor samples of 9 (47%) patients. VEGF165 and EGF expression in the same tumor correlates significantly (P < 0.05, Fisher-test). UICC stage III pancreatic carcinoma patients with VEGF165 negative tumor cells had a significantly better outcome after surgery compared to UICC stage III patients with VEGF165-positive tumor cells (median survival time 19 months vs. 9 months respectively; P < 0.05, Wilcoxon-test).

CONCLUSIONS

Antiangiogenic therapy after surgery for pancreatic cancer may be beneficial, especially for UICC III patients.

The improvised atraumatic suture: a cost-reducing technique, not only for the tropics?

A simple technique to produce your own atraumatic suture is described. All that is needed is a simple injection needle and any kind of thread.The thread is introduced into the cavity of the needle and fixed by squeezing its end after having broken the hub. This method is very easy to apply and extremely economical.

Neoadjuvant radio-chemotherapy of adenocarcinoma of the oesophagogastric junction

BACKGROUND

Recently, neoadjuvant radio-chemotherapy has been demonstrated to induce tumour remission and to prolong survival of patients with locally advanced adenocarcinoma of the oesophagogastric junction.The present study was performed to re-evaluate these data.

PATIENTS AND METHOD

A non-randomised trial of multimodal treatment was conducted in order to investigate histopathologic response and survival of patients with adenocarcinoma of the oesophagogastric junction. Treatment consisted of 2 courses of combined chemotherapy with 15 mg/kg 5-fluorouracil on days 1-5 and 75 mg/m(2) cisplatin on day 8 and simultaneous radiation (40 Gy), and a second course starting on day 36, followed by surgery. Abdomino-thoracic oesophagectomy and systematic 2-field lymphadenectomy were performed in patients with Barrett's carcinoma. D2-gastrectomy was performed in patients with type 2 or 3 cancer of the oesophagogastric junction according to the Siewert classification. Probability of survival was estimated using the Kaplan-Meier method.

RESULTS

16 patients with a mean age of 57 years were enrolled in this study. Surgery was performed in 14 of these patients. Response to treatment was evident in 10 patients, but none of these patients had complete histopathologic response. Toxicity related to radiochemotherapy was mild to moderate (37.5%). Perioperative complications, both medical and surgical, occurred in 71.4% of patients. 2 patients had fatal complications. 30-day mortality was 25.4%. The probability of survival at 2 years after surgery was 61.2%.

CONCLUSION

Neoadjuvant radio-chemotherapy followed by surgery for cancer of the oesophagogastric junction is associated with a considerable rate of complications. Histopathologic response to radio-chemotherapy is poor. In consequence of these preliminary results, the present study was terminated and the protocol of a future study was modified.

Sphincter-saving treatment in epidermoid anal cancer: cooperative analysis of 142 patients in five German university surgical centers

Five southern German university centers cooperated in comparing the effect of surgical vs. nonsurgical therapy strategies on survival and sphincter preservation in the treatment of anal cancer. A standardized questionnaire was used to evaluate retrospectively (mean follow-up 30 months) treatment strategy and outcome (survival, colostomy rate, colostomy-free survival) in patients treated between 1987 and 1996. Of the 142 patients 65% had squamous cell, 20% basaloid, 6% adeno-, and 1% undifferentiated carcinoma (8% histology not recorded); 9% were classified in UICC stage I, 37% in stage II, 25% in stage III, and 4% in stage IV (25% not recorded). Primary treatment consisted of local excision (10%), excision plus radio- and/or chemotherapy (17%), radiotherapy (20%), radiochemotherapy (28%), or colostomy with or without resection, radiotherapy, and chemotherapy (23%). We observed no difference between these treatment groups in overall (P = 0.43) or colostomy-free survival (P = 0.14, log-rank). Primary colostomy was prevented in 77% of cases and decreased over the years. Mean overall survival (in months) was 42 in stage I, 38 in stage II, and 25 in stage III (P = 0.0013); mean colostomy-free survival was 36 in stage I, 26 in stage II, and 16 in stage III (P = 0.0021, log-rank). Outcome was not significantly related to therapeutic strategy (surgery or radio-chemotherapy. Primary surgical and nonsurgical strategies in treating anal cancer thus produced similar results, although radiochemotherapy is usually recommended for sphincter-endangering anal cancer. Challenges to be met in the future include the prevention of metastasis and long-term preservation of anal sphincter function.

[Multiple trauma and the management structure]

The implementation of Quality Management Procedures is necessary in evaluating the treatment of multiple trauma-patients. The development of standards in structures of the trauma management system is the first step to insure quality (appraisal of structure). But the amount of investment in the trauma system structure is limited by 1. The resources available, 2. The efficacy of the applied resources, i.e. the principle of diminishing returns of investment. Centralization of care in Level I Trauma Centers is not realistic in every situation. Transport time can be too long and exceed the critical "golden hour". Review of current data indicates that in approximately 50% of the time, helicopter transport is not possible due to weather, geography, or other limiting factors. This leads to a fragmented transport system, often necessitating extensive transport times, resulting in less than optimal patient outcomes. In order to optimize quality, the following needs to be done: Assessment of process: 1. Realistic algorithms or protocols for primary transport must be developed. 2. Agreements must be reached between designated regional hospitals. 3. Treatment algorithms or protocols which address the different care levels, must be developed by a committee of clinical experts. 4. Quality management procedures must be implemented to monitor the quality of care delivered. Assessments of outcomes: 1. Outcome data must be reviewed on an ongoing basis to determine if changes must be made in the system design or the transportation & clinical algorithms/protocols. 2. Such outcome data should be gathered by means of a Trauma Registry.

MRI with superparamagnetic iron oxide: efficacy in the detection and characterization of focal hepatic lesions

The purpose of this study was to evaluate the potential of superparamagnetic iron oxide particles (SPIO) as tissue specific contrast agent in magnetic resonance (MR) imaging in detection and characterization of focal hepatic lesions. We investigated 45 patients with focal hepatic lesions. T1-weighted SE (TR 650/TE 15 ms) and T2-weighted SE (TR 2015-2030/TE 45 and 90 ms) unenhanced images were obtained. After SPIO application we performed T1-weighted images with and T2-weighted images with and without fat suppression using the same image parameters. Liver signal intensity decreased by 74% (min 47%, max 83%) on T2-weighted images after application of the contrast agent. Benign lesions (FNH, adenoma) showed an average signal drop of 40% (min 20%, max 47%) whereas malignant lesions showed no significant change of signal intensity on post-contrast images. The mean tumor-to-liver contrast-to-noise ratio (C/N) was improved in all post-contrast sequences irrespective of the lesion type. An additional increase of tumor-to-liver contrast by use of fat suppression technique could be established in the slightly T2-weighted sequence (TE 45 ms). In metastases, divided in different size groups, we could determine a significant size relation of tumor-to-liver C/N. After SPIO application the number of detected lesions increased distinctly, especially small foci are more easily demonstrated. SPIO particles are a efficacious contrast agent for MR examinations of the liver. For tumor characterization T1- and T2-weighted pre- and post-contrast images are necessary. The T1-weighted sequences are helpful to differentiate benign lesions such as cysts and hemangiomas from malignant lesions. Detection and differential diagnoses of hepatic lesions are improved by use of the SPIO-particles.

[Adjuvant radiochemotherapy with 5-FU and folinic acid in Dukes stage B and C rectum carcinoma: an interim analysis]

In a prospective multi-institutional German adjuvant trial patients with curatively resected rectal cancer (Dukes B or C) were randomly assigned to receive postoperative radiotherapy (50.4 Gy) and either 12 or 6 cycles of 5-fluorouracil and medium-dose folinic acid. Our preliminary results of the interim analysis, based on 206 patients, indicate that this adjuvant therapy is well tolerated by the patients and a prolonged chemotherapy over 12 months has no advantage over 6 months of chemotherapy. The relatively high rate of tumor recurrence (30.7%) after a median follow-up of 29.3 months in this trial emphasizes the need for dose intensification planned for a further trial.

[Ultrafast contrast-enhanced 3D MR angiography in the preoperative diagnosis of liver tumors]

PURPOSE

To evaluate the accuracy of 3D-MRA in preoperative staging in correlation to intraoperative and histological results.

METHODS

In 30 patients with focal liver lesions axial and coronal MR sequences (T1w-Flash 2D, T2w-TSE unenhanced. T1w-Flash 2D, TRUE FISP contrast-enhanced) as well as coronal breath-hold MRA were performed. The technical parameters of the MRA were as follows; TR/TE 5/2 ms, flip angle 40 degrees, 32-40 partitions with an effective slice thickness of 2-3 mm, acquisition time 26 s, matrix 128 x 256, FOV 320 x 320 to 400 x 400.

RESULTS

In 23/30 patients liver resection was performed. Correct prediction of segmental localization was achieved in preoperative MRI of 22 patients (98%). The presumed histology was correct in 20/23 cases (87%). The evaluation of the hepatic vascular structures was correctly predicted in all cases. By use of multiplanar reconstructions and single image view of the 3D data base of MRA, additional information could be obtained in 13 patients.

CONCLUSIONS

Breath-hold 3D-MRA gives certain information on localization and relation of vascular structures to focal hepatic lesions. In presentation of portal venous structures MRA is superior to conventional angiography.

Migration of single-stranded DNA in polyacrylamide gels during electrophoresis

By using fluorescence recovery after photobleaching (FRAP) and electric birefringence, the migration of single-stranded DNA in polyacrylamide gels and orientation as a response to an electric pulse were investigated. Electrophoretic mobility is in good agreement with the model of biased reptation including fluctuations. The determination of the electrophoretic mobility in solution, mu0, allows an estimation of the gel pore diameter seen by the molecule. As previously observed for double-stranded DNA, the electric birefringence results from two processes: the alignment of the molecule along the electric field and the elongation of the primitive path in the gel, for long single-stranded DNA (>2000 bases). The combination of results obtained with the two techniques allows us to propose experimental conditions to improve the separation of single-stranded DNA with pulsed field techniques.

[Ultra-rapid magnetic resonance tomography: a quantum leap in preoperative hepatobiliary diagnosis?]

The recent improvements in magnetic resonance (MR) imaging using the new ultrafast echo-planar technique for diagnosis of hepatobiliary lesions are outstanding. Besides the detection and preoperative evaluation of benign and malignant hepatobiliary tumors, angiography and cholangiography can be simultaneously performed using the techniques of MR angiography or MR cholangiography. Looking ahead, further advantages such as three-dimensional image reconstruction, no X-ray exposure, and short examination time, this MR technique will become the preferred diagnostic procedure for evaluating hepatobiliary lesions.

[Magnetic resonance tomography in diagnosis of vascular infiltration in malignant pancreas tumors]

This study was undertaken to evaluate the accuracy of magnetic resonance angiography (MRA) in assessing venous or arterial infiltration in pancreatic cancer. In 90 patients MRA showed a sensitivity of 81.1%, a specificity of 90.2% and an accuracy of 85.9% in predicting venous infiltration and a sensitivity of 81.8%, a specificity of 90.7% and an accuracy of 88.1% in predicting arterial infiltration. From these data we conclude that MRA is an accurate method for detecting vascular infiltration in pancreatic cancer.

Trocar incision and closure: daily problems in laparoscopic procedures--a new technical aspect

A mini-laparotomy as described by Hasson was used in a modified way in 1,500 laparoscopic procedures. In comparison with the insertion of a Veress needle, we find the open approach to be a safer and quicker technique to obtain the pneumoperitoneum. A new technique for closure of the trocar incision is described. The technique is recommended due to its easy and safe approach requiring no additional special equipment.

Cystic endometriosis of the upper abdominal organs. Report on three cases and review of the literature

A 34-year-old woman with signs and symptoms of an acute abdomen was found to have a hepatic cyst on NMR- and CT-scan. With the tentative diagnosis of a liver hematoma, a right hemihepatectomy was performed. Histologically, an endometrial cyst of the liver was found. A second case of cystic endometriosis in the liver was revealed ultrasonographically in a 62-year-old woman, complaining of rightsided epigastrical pain. A 28-year-old woman was admitted to the hospital because of recurrent epigastric pain. A cystic tumor of the pancreas could be visualized ultrasonographically and was interpreted as a postinflammatory pseudocyst. Histological examination of the distal pancreatectomy specimen revealed cystic endometriosis. The clinicopathological features of hepatic and pancreatic endometriosis are discussed and the literature concerning these extremely rare lesions is reviewed.

Dynamics of DNA molecules in agarose gel under sinusoidal electric fields

The dynamics of DNA molecules in agarose gel has been studied by measuring the birefringence in sine wave electric fields. It was found that the birefringence is the sum of a direct current (dc) component and several harmonics of the field frequency. A detailed study of these components was performed. It was found that the dynamics of DNA molecules under these conditions can be explained by a W conformation which is not detected under dc electric fields. The variation of the field frequency gives several relaxation modes in the birefringence signal, reflecting the known dynamic behavior of DNA molecules found in the reputation with elongation of the tube length regime.

[Comparative study of the quality of life after stomach resection]

In the present study, 195 patients, following total gastrectomy (n = 105) or subtotal gastric resection (n = 90) for carcinoma without evidence of recurrence, were examined with regard to their quality of life using the Gastrointestinal Quality-of-Life Index (GLQI). After subtotal gastric resection patients achieved statistically significant better scores concerning disease-therapy-related symptoms and physical functions, resulting in a better overall score (p < 0.02). However, it seems to be questionable whether these statistically significant differences are of clinical relevance in the patient's daily life. Preservation of the gastric stump with the aim of improving postoperative quality of life should never be allowed to compromise oncological radicality.

Dynamics of single-stranded DNA in polyacrylamide gels during pulsed field gel electrophoresis. A birefringence study

The study of the orientation of single-stranded DNA in polyacrylamide gels in denaturing conditions has been undertaken by electric birefringence in order to determine the mechanism involved in the electrophoretic transport. The presence of an overshoot in the birefringence signal, when applying the electric field, and the study of the influences of the electric field and of the gel concentration on the dynamics show that a mechanism of reptation with elongation of the molecule occurs in polyacrylamide gels with low T values. Therefore it is suggested that the use of pulsed fields in sequencing electrophoresis is possible and can lead to a large increase of the length of the fragments that can be sequenced in one single run.