Effect of Hyperthermic Intraperitoneal Chemotherapy on Cytoreductive Surgery in Gastric Cancer With Synchronous Peritoneal Metastases: The Phase III GASTRIPEC-I Trial

PURPOSE

In patients with peritoneal metastasis (PM) from gastric cancer (GC), chemotherapy is the treatment of choice. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are still being debated. This randomized, controlled, open-label, multicenter phase III trial (EudraCT 2006-006088-22; ClinicalTrials.gov identifier: NCT02158988) explored the impact on overall survival (OS) of HIPEC after CRS.

PATIENTS AND METHODS

Adult patients with GC and histologically proven PM were randomly assigned (1:1) to perioperative chemotherapy and CRS alone (CRS-A) or CRS plus HIPEC (CRS + H). HIPEC comprised mitomycin C 15 mg/m2 and cisplatin 75 mg/m2 in 5 L of saline perfused for 60 minutes at 42°C. The primary end point was OS; secondary endpoints included progression-free survival (PFS), other distant metastasis-free survival (MFS), and safety. Analyses followed the intention-to-treat principle.

RESULTS

Between March 2014 and June 2018, 105 patients were randomly assigned (53 patients to CRS-A and 52 patients to CRS + H). The trial stopped prematurely because of slow recruitment. In 55 patients, treatment stopped before CRS mainly due to disease progression/death. Median OS was the same for both groups (CRS + H, 14.9 [97.2% CI, 8.7 to 17.7] months v CRS-A, 14.9 [97.2% CI, 7.0 to 19.4] months; P = .1647). The PFS was 3.5 months (95% CI, 3.0 to 7.0) in the CRS-A group and 7.1 months (95% CI, 3.7 to 10.5; P = .047) in the CRS + H group. The CRS + H group showed better MFS (10.2 months [95% CI, 7.7 to 14.7] v CRS-A, 9.2 months [95% CI, 6.8 to 11.5]; P = .0286). The incidence of grade ≥3 adverse events (AEs) was similar between groups (CRS-A, 38.1% v CRS + H, 43.6%; P = .79).

CONCLUSION

This study showed no OS difference between CRS + H and CRS-A. PFS and MFS were significantly better in the CRS + H group, which needs further exploration. HIPEC did not increase AEs.

Statin and rottlerin small-molecule inhibitors restrict colon cancer progression and metastasis via MACC1

MACC1 (Metastasis Associated in Colon Cancer 1) is a key driver and prognostic biomarker for cancer progression and metastasis in a large variety of solid tumor types, particularly colorectal cancer (CRC). However, no MACC1 inhibitors have been identified yet. Therefore, we aimed to target MACC1 expression using a luciferase reporter-based high-throughput screening with the ChemBioNet library of more than 30,000 compounds. The small molecules lovastatin and rottlerin emerged as the most potent MACC1 transcriptional inhibitors. They remarkably inhibited MACC1 promoter activity and expression, resulting in reduced cell motility. Lovastatin impaired the binding of the transcription factors c-Jun and Sp1 to the MACC1 promoter, thereby inhibiting MACC1 transcription. Most importantly, in CRC-xenografted mice, lovastatin and rottlerin restricted MACC1 expression and liver metastasis. This is-to the best of our knowledge-the first identification of inhibitors restricting cancer progression and metastasis via the novel target MACC1. This drug repositioning might be of therapeutic value for CRC patients.

Local recurrence rates after radiofrequency ablation or resection of colorectal liver metastases. Analysis of the European Organisation for Research and Treatment of Cancer #40004 and #40983

AIM

The aim of this study is to describe local tumour control after radiofrequency ablation (RFA) and surgical resection (RES) of colorectal liver metastases (CLM) in two independent European Organisations for Research and Treatment of Cancer (EORTC) studies.

BACKGROUND

Only 10-20% of patients with newly diagnosed CLM are eligible for curative RES. RFA has found a place in daily practice for unresectable CLM. There are no prospective trials comparing RFA to RES for resectable CLM.

METHODS

The CLOCC trial randomised 119 patients with unresectable CLM between RFA (±RES)+adjuvant FOLFOX (±bevacizumab) versus FOLFOX (±bevacizumab) alone. The EPOC trial randomised 364 patients with resectable CLM between RES±perioperative FOLFOX. We describe the local control of resected patients with lesions ≤4 cm in the perioperative chemotherapy arm of the EPOC trial (N=81) and the RFA arm of the CLOCC trial (N=55).

RESULTS

Local recurrence (LR) rate for RES was 7.4% per patient and 5.5% per lesion. LR rate for RFA was 14.5% per patient and 6.0% per lesion. When lesion size was limited to 30 mm, LR rate for RFA lesions was 2.9% per lesion. Non-local hepatic recurrences were more often observed in RFA patients than in RES patients, 30.9% and 22.3% respectively. Patients receiving RFA had a more advanced disease.

CONCLUSIONS

LR rate after RFA for lesions with a limited size is low. The local control per lesion does not appear to differ greatly between RFA and surgical resection. This study supports the local control of RFA in patients with limited liver metastases. Future studies should evaluate in which patients RFA could be an equal alternative to liver resection.

Impact of mutant β-catenin on ABCB1 expression and therapy response in colon cancer cells

Background:

Colorectal cancers are often chemoresistant toward antitumour drugs that are substrates for ABCB1-mediated multidrug resistance (MDR). Activation of the Wnt/β-catenin pathway is frequently observed in colorectal cancers. This study investigates the impact of activated, gain-of-function β-catenin on the chemoresistant phenotype.

Methods:

The effect of mutant (mut) β-catenin on ABCB1 expression and promoter activity was examined using HCT116 human colon cancer cells and isogenic sublines harbouring gain-of-function or wild-type β-catenin, and patients’ tumours. Chemosensitivity towards 24 anticancer drugs was determined by high throughput screening.

Results:

Cell lines with mut β-catenin showed high ABCB1 promoter activity and expression. Transfection and siRNA studies demonstrated a dominant role for the mutant allele in activating ABCB1 expression. Patients’ primary colon cancer tumours shown to express the same mut β-catenin allele also expressed high ABCB1 levels. However, cell line chemosensitivities towards 24 MDR-related and non-related antitumour drugs did not differ despite different β-catenin genotypes.

Conclusion:

Although ABCB1 is dominantly regulated by mut β-catenin, this did not lead to drug resistance in the isogenic cell line model studied. In patient samples, the same β-catenin mutation was detected. The functional significance of the mutation for predicting patients’ therapy response or for individualisation of chemotherapy regimens remains to be established.

Novel Clostridium perfringens enterotoxin suicide gene therapy for selective treatment of claudin-3- and -4-overexpressing tumors

Bacterial toxins are known to be effective for cancer therapy. Clostridium perfringens enterotoxin (CPE) is produced by the bacterial Clostridium type A strain. The transmembrane proteins claudin-3 and -4, often overexpressed in numerous human epithelial tumors (for example, colon, breast, pancreas, prostate and ovarian), are the targeted receptors for CPE. CPE binding to them triggers formation of membrane pore complexes leading to rapid cell death. In this study, we aimed at selective tumor cell killing by CPE gene transfer. We generated expression vectors bearing the bacterial wild-type CPE cDNA (wtCPE) or translation-optimized CPE (optCPE) cDNA for in vitro and in vivo gene therapy of claudin-3- and -4-overexpressing tumors. The CPE expression analysis at messenger RNA and protein level revealed more efficient expression of optCPE compared with wtCPE. Expression of optCPE showed rapid cytotoxic activity, hightened by CPE release as bystander effect. Cytotoxicity of up to 100% was observed 72 h after gene transfer and is restricted to claudin-3-and -4-expressing tumor lines. MCF-7 and HCT116 cells with high claudin-4 expression showed dramatic sensitivity toward CPE toxicity. The claudin-negative melanoma line SKMel-5, however, was insensitive toward CPE gene transfer. The non-viral intratumoral in vivo gene transfer of optCPE led to reduced tumor growth in MCF-7 and HCT116 tumor-bearing mice compared with the vector-transfected control groups. This novel approach demonstrates that CPE gene transfer can be employed for a targeted suicide gene therapy of claudin-3- and -4-overexpressing tumors, leading to the rapid and efficient tumor cell killing in vitro and in vivo.

The impact of short-term psycho-oncological interventions on the psychological outcome of cancer patients of a surgical-oncology department - a randomised controlled study

BACKGROUND

Anxiety and depression are the two most frequent comorbidities of tumour patients. At present, it is unclear to which degree a patient's psychological condition can be altered during the treatment period and if psycho-oncological support positively affects a patient's psychological condition.

METHODS

In a random sample analyses, 131 patients beginning inpatient treatment at a hospital specialising in surgical oncology were either classified as 'low-risk' or 'high-risk', according to the HADS. Patients from both categories were then randomly placed in either a low-threshold 'intervention' group or an 'observation' group. Anxiety and depression levels were measured again with the HADS scale prior to the patients discharge from the department of surgical oncology, and at a follow up 12 months after.

RESULTS

Our findings showed a significant reduction of anxiety and depression in the high-risk patients who had undergone psycho-oncological intervention at the end of inpatient care and even a year after discharge from the hospital. The effects of psychological intervention could be observed in terms of anxiety and depression in the group of high-risk patients during the hospital stay. In the other three groups, no statistically significant changes could be measured.

CONCLUSION

Cancer patients on a surgical ward benefit from psycho-oncological support especially at an early stage of therapy but also over a long time after discharge from the hospital. The aim of all interventions should be to decrease psychological distress and disorders and thereby improve the quality of life for cancer patients.

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

BACKGROUND

Oesophageal anastomotic leakage is associated with considerable morbidity and mortality. The aim of the present study was to assess the feasibility of using temporary self-expanding plastic stents to treat postoperative oesophageal leaks.

METHODS

Patients with anastomotic leakage after abdominothoracic oesophagectomy treated by endoscopic insertion of self-expanding plastic stents between 2001 and 2007 were studied. Clinical outcomes were analysed, including healing of the leak, morbidity and mortality.

RESULTS

Stents were inserted successfully in all 22 patients without procedure-related complications. Ten patients also required computed tomography-guided drainage because surgical drains had been removed. Non-ventilated patients received oral nutrition a mean of 4 days after stent placement. Combined treatment with stenting and drainage resulted in resolution of the leak in 21 of 22 patients. The mean healing time (time to stent removal) was 23 days. Stent migration occurred in five of 22 patients, but endoscopic reintervention with placement of a new stent was successful in all patients. Repeat thoracotomy with intraoperative stent placement was necessary in one patient with an oesophagocolonic anastomosis. One patient died in hospital.

CONCLUSION

In combination with effective drainage, self-expanding plastic stents are an option for the treatment of oesophageal anastomotic leaks, and may reduce leak-related morbidity and mortality.

Efficiency of adjuvant active specific immunization with Newcastle disease virus modified tumor cells in colorectal cancer patients following resection of liver metastases: results of a prospective randomized trial

PURPOSE

Metastatic disease is a major cause of mortality in colorectal cancer patients. Even after complete resection of isolated liver metastases, recurrence develops in the majority of patients. Therefore, development of strategies to prevent recurrent liver metastases is of major clinical importance. The present prospectively randomised phase III trial investigates the efficiency of active specific immunotherapy (ASI) after liver resection for hepatic metastases of colorectal cancer.

METHODS

Patients with histologically confirmed liver metastases from colorectal cancer were randomised to the vaccination or control group. After complete resection of liver metastases, patients randomised to the vaccination group received six doses of Newcastle disease virus (NDV) infected autologous tumour cell vaccine (ATV-NDV). The primary end-point was overall survival, secondary end-points were disease-free survival and metastases-free survival.

RESULTS

Fifty-one patients were enrolled in the study with 50 patients available for analysis. The follow-up period was 116.1 +/- 23.8 month in the vaccination arm and 112.4 +/- 18.5 month in the control group. In the total patient group, no differences in the primary and secondary end-points were detected. Most interestingly, subgroup analysis revealed a significant advantage for vaccinated colon cancer patients with respect to overall survival [hazard ratio: 3.3; 95%, confidence interval (CI): 1.0-10.4; P = 0.042] and metastases-free survival (hazard ratio: 2.7; 95%, CI: 1.0-7.4; P = 0.047) in the intention-to-treat analysis.

CONCLUSION

Active specific immunotherapy in unselected colorectal cancer patients was not effective for prevention of recurrent metastatic disease. However, in colon cancer patients, ASI with ATV-NDV appears to be beneficial prolonging overall and metastases-free survival.

A new measure to assess the difficulty of liver resection

BACKGROUND

There is no valid measure to assess surgical difficulty and feasibility of a planned liver resection. It is the objective of this study to evaluate a mathematical measure from a 3D graphical analysis.

METHODS

Eleven different 3D models of hepatic tumours were evaluated by experts for resectability and analysed with Amira graphic software taking into consideration the portal and hepatic venous vascular relationships. Virtual resection volumes with increasing resection margins from 1 to 30 mm were determined separately for portal veins, hepatic veins, their intersections and volume unions. The integral of the increasing resection volumes was defined as risk coefficient. The risk coefficients from this volumetric analysis were compared with the expert opinion.

RESULTS

The risk coefficient based on the integral of portal venous and hepatic venous volume unions reproduced the expert opinion highly significantly (correlation coefficient 0.9, p<0.05) and more accurately than volumetric analysis of the planned resection margin.

CONCLUSION

With automated volumetric analysis, anatomically problematic situations in liver surgery can be reproduced and scaled. The risk coefficient obtained is a suitable objective measure for defining risk areas in liver surgery.

The location of small tumor deposits in the SLN predicts Non-SLN macrometastases in breast cancer patients

AIMS

The extent to which the location of micrometastases (MIC) or isolated tumor cells (ITC) in sentinel lymph nodes (SLNs) is correlated with the risk of downstream metastases is still unknown. This study examined this issue and compared the impact of MIC/ITC location with other established risk factors.

METHODS

Paraffin slides of SLNs with MIC/ITC-involvement obtained from 68 breast cancer patients were evaluated for MIC/ITC location, lesion size, and various SLN morphologic features. These parameters, together with demographic data and primary tumor characteristics, were analyzed using univariate and multivariate analysis to determine their association with the presence of downstream macrometastases in Non-SLN.

RESULTS

Eighteen of 68 patients with MIC (n=37) or ITC (n=31) had Non-SLN metastases. After multivariate analysis, the location of MIC/ITC in the SLN (parenchyma vs. sinus/vessel) had the strongest association with the presence of Non-SLN macrometastases (p<0.0001), followed by the pT-category (p=0.008). Sixteen of 18 patients with parenchymal involvement but only 2 of 31 without parenchymal involvement had Non-SLN macrometastases. The metric size of the primary tumor and the estrogen receptor status were significantly associated only on univariate analysis (p=0.041, 0.034), whereas the correlation to the size classification for tumor cell deposits (MIC vs. ITC) was not significant (p=0.077).

CONCLUSIONS

The results indicate that lesion location is an important predictor of Non-SLN-macrometastases. This finding may simplify the decision for axillary treatment in patients with small tumor deposits in the SLN.

Sentinel node biopsy in synovial sarcoma

AIMS

To examine the relevance of sentinel node biopsy in patients with synovial sarcoma.

METHODS

Between July 2004 and February 2007 11 consecutive patients with synovial sarcoma treated in our clinic underwent sentinel node biopsy after a preoperative lymphoscintigraphy. A handheld gamma-probe was used during the procedure to identify the sentinel nodes, which were then resected and submitted for histopathologic evaluation.

RESULTS

At least one sentinel node was identified in every patient. Of a total of 15 sentinels, one was positive and 14 negative. The patient with the positive sentinel underwent a regional lymph node dissection and remains disease-free 17 months later. One patient developed regional nodal metastases despite negative sentinel node biopsy and died 12 months after the procedure. No biopsy-associated complications were observed.

CONCLUSIONS

Sentinel node biopsy can be successfully and safely applied to patients with synovial sarcoma. Further prospective studies are required to determine the optimal treatment approach, the false negative rate and the prognostic significance of a positive sentinel node biopsy.

Presence of mature DC-Lamp+ dendritic cells in sentinel and non-sentinel lymph nodes of breast cancer patients

AIM

Our study examined differences in the presence of mature, DC-Lamp+ DC in the SLN and non-SLN according to the extent of metastatic involvement.

PATIENTS AND METHODS

Paraffin blocks of the SLN and non-SLN from patients with primary breast cancer who had undergone SLN biopsy and axillary dissection were separated into three groups: (Group A) no tumor cell involvement in the SLN and non-SLN; (Group B) isolated tumor cells or micrometastases in the SLN, and tumor cell-free non-SLN; and (Group C) macrometastases in the SLN. One section of all the SLN and non-SLN was examined with immunohistochemistry using an anti-DC-Lamp-antibody. The densest area occupied by the DC-Lamp+ cells on each slide was quantified and recorded by an electronic imaging system. In this regard, the SLN and non-SLN were compared within the patients of each group using the Wilcoxon signed rank-test (p<0.05).

RESULTS

One hundred and fourteen SLN and 1258 non-SLN from 79 patients were examined. A significantly larger area was occupied by the DC-Lamp(+) cells in the SLN compared to the non-SLN in Groups A (p=0.024) and B (p=0.009), whereas no significant difference was found within Group C (p=0.107).

CONCLUSIONS

This study suggests that the DC-dependent immune response is altered during the process of metastasis formation and is primarily activated before and during formation of micrometastasis.

[R1 resection in the region of the lower gastrointestinal tract: relevance and therapeutic consequences]

Incomplete resection (R1) and local recurrence of colorectal cancer continue to be a significant surgical problem. Radical resection of bowel and lymph node bassin are clearly necessary after incomplete endoscopic resection or local surgical excision. However, the situation is more difficult after previous conventional surgery. Anastomotic recurrence following resection and lymph nodal recurrence can often precede curative reresection. Locoregional lymph node metastases due to incomplete surgical clearance of the lymphatic drainage of colonic cancer may also be cured by radical reresection. Despite application of neoadjuvant therapy, integration of modern surgical concepts such as the circumferential resection margin and advances in surgical technique, R1 resection of rectal cancer remains a major problem. Although primary surgical therapy may be considered in selected cases, this situation will require multimodal therapy in most instances.

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

AIM

Although 15-25% of patients with anal cancer present with superficial inguinal lymph node metastases but the routine application of groin irradiation is controversial because of serious side effects. Inguinal sentinel lymph node biopsy (SLNB) can be used to select patients appropriately for inguinal radiation. The study evaluates the efficiency and clinical impact of SLNB.

METHODS

Forty patients with anal cancer underwent 1 ml Tc(99m)-Nanocolloid injection in four sites around the tumour. Patients with inguinal radio colloid enrichment were selected for sentinel lymph node biopsy (SLNB). Lymph node status was examined by haematoxylin and eosin (H&E) as well as immunohistochemistry-staining. All SLN-positive patients were scheduled for inguinal radiation; SLN-negative patients with T1 and early T2 tumours were not scheduled for inguinal radiation.

RESULTS

SLN were detected in 36/40 patients. Three common patterns of lymphatic drainage were observed: mesenterial, iliacal and inguinal. Twenty patients with inguinal SLN underwent SLN-biopsy. 6/20 patients were SLN-positive. In 10/20 patients SLNB altered the therapy plan--four patients with T1-tumours and positive SLN had additional groin irradiation, whereas 6 patients with small T2-tumors and tumour-free inguinal SLN did not undergo inguinal irradiation.

CONCLUSIONS

Inguinal sentinel node biopsy in anal cancer is efficient and could assist in the decision for inguinal radiation. The validity and safety of the proposed therapeutic algorithm has to be proven by a larger, prospective study.

Evaluation of higher-order time-domain perturbation theory of photon diffusion on breast-equivalent phantoms and optical mammograms

Time-domain perturbation theory of photon diffusion up to third order was evaluated for its accuracy in deducing optical properties of breast tumors using simulated and physical phantoms and by analyzing 141 projection mammograms of 87 patients with histology-validated tumors that had been recorded by scanning time-domain optical mammography. The slightly compressed breast was modeled as (partially) homogeneous diffusely scattering infinite slab containing a scattering and absorbing spherical heterogeneity representing the tumor. Photon flux densities were calculated from densities of transmitted photons, assuming extended boundary conditions. Explicit formulas are provided for second-order changes in transmitted photon density due to the presence of absorbers or scatterers. The results on phantoms obtained by perturbation theory carried up to third order were compared with measured temporal point spread functions, with numerical finite-element method (FEM) simulations of transmitted photon flux density, with results obtained from the diffraction of diffuse photon density waves, and from Padé approximants. The breakdown of first-, second-, and third-order perturbation theory is discussed for absorbers and a general expression was derived for the convergence of the Born series in this case. Taking tumor optical properties derived by the diffraction model as reference we conclude that estimates of tumor absorption coefficients by perturbation theory agree with reference values within +/-25% in only 65% (first order), 66% (second order), and 77% (third order) of all mammograms analyzed. In the remaining cases tumor absorption is generally underestimated due to the breakdown of perturbation theory. On average the empirical Padé approximants yield tumor absorption coefficients similar to third-order perturbation theory, yet at noticeable lower computational efforts.

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

AIMS

Vascular endothelial growth factors VEGF-A, VEGF-C and VEGF-D are considered to be potentially angiogenetic and lymphangiogenetic. "Minimal residual disease" is responsible for cancer progression and recurrence. In this study, we investigated the relation between expressions of VEGF-A, VEGF-C and VEGF-D in gastric cancer tissue and the presence of tumour cells in bone marrow.

METHODS

A total of 50 resected primary gastric adenocarcinomas, 44 non-cancerous gastric mucosa and 36 lymph node metastases were analyzed by immunohistochemistry for VEGF-A, VEGF-C and VEGF-D. The specimens used were drawn from a previous study cohort, where the presence of ITC in bone marrow was confirmed with immunohistochemical assay with cytokeratin (CK)-18.

RESULTS

The levels of expression of VEGF-A, VEGF-C and VEGF-D were highest in tumour (p < 0.001), and the level in lymph node metastases was significantly higher (p < 0.01) than in mucosa. The expression of VEGF-A was correlated significantly with venous tumour invasion (p < 0.05) and the presence of tumour cells in bone marrow (p < 0.05). Tumours expressing high levels of VEGF-D showed significantly advanced stages of tumour infiltration (p < 0.05) and lymph node metastasis (p < 0.01).

CONCLUSIONS

VEGF-A is a significant marker for the presence of tumour cells in the bone marrow of gastric cancer patients. Our results confirm VEGF-D as a predictor for the lymphatic spread of tumour cells. Therefore, the route of metastatic spread of gastric cancer could be determined, at least in part, by the profile of VEGF family members expressed in the primary tumour of gastric cancer patients.

Sentinel lymph node biopsy for gastrointestinal cancers

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

Image-guided surgery of liver metastases by three-dimensional ultrasound-based optoelectronic navigation

BACKGROUND

Vessel-oriented surgery and tumour-free resection margins are essential for resection of liver metastases to preserve liver parenchyma and improve oncological outcome. Preoperative three-dimensional models reconstructed from imaging data could facilitate surgical planning with the use of navigation technology.

METHODS

Thirty-three patients with central and/or impalpable liver metastases were scheduled for navigated hepatic resection. Intraoperative three-dimensional ultrasonography and an infrared-based optical tracking system were used for data registration and image-guided surgery. Postoperative three-dimensional data were compared with the preoperative virtual surgical plan to assess the accuracy of navigation, and clinical results were compared with those of a matched control group of 32 patients.

RESULTS

Navigation was successful in 32 of 33 patients. Realization of the preoperative plan and R0 resection was achieved in 30 of these 32 patients. The median discrepancy between the planned and actual vascular dissection level was 6 (range 0-11) mm. There was a reduced rate of R1 resection in the navigated group compared with the control group (two versus four patients), and more parenchyma was preserved.

CONCLUSION

Three-dimensional ultrasound-based optoelectronic navigation technology improves intraoperative orientation and enables parenchyma-preserving surgery with high precision.

Development and validation of a three dimensional ultrasound based navigation system for tumor resection

BACKGROUND

Intraoperative navigation is a rapidly emerging procedure in orthopaedic surgery and neurosurgery. For abdominal tumors (e.g. liver metastasis) and soft tissue tumors there is only limited experience with navigation techniques due to problems of organ shift and tissue deformation. We have developed a navigation system for tumor resection in soft tissue based on 3D ultrasound imaging and optical tracking.

METHODS

Two different modes of navigation were evaluated and compared with conventional surgery in an experimental soft tissue model. Both techniques were based on 3D ultrasound and an optical tracking system for intraoperative real time registration of surgical instruments. These two techniques were used: a) Indirect navigation with ultrasound guided insertion of a tracked hook needle into the tumor; and b) Direct navigation using a 3D image which was obtained with an optically tracked 3D ultrasound probe. It was the aim of both techniques to achieve a circumferential resection margin of 2cm around the tumor.

RESULTS

A total of 23 resections were performed consisting of indirect (n=7) and direct (n=10) navigation and conventional surgery (n=6) as gold standard. For indirect navigation a median deviation from the ideal resection margin (accuracy) of 0.32cm was measured. Direct navigation showed an accuracy of 0.16cm compared to 0.42cm with conventional surgery. Navigated surgery showed for both techniques a significant increase of resection accuracy compared to conventional resection (p<0.05).

CONCLUSION

3D ultrasound based indirect and direct optoelectronic navigation for resection of soft tissue tumors is feasible and may improve intraoperative orientation with increased surgical precision.

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.