It is everywhere-A survey on the presence of carp edema virus in carp populations in Germany

Carp edema virus (CEV) is the causative agent of koi sleepy disease (KSD), a serious gill disease affecting common carp, Cyprinus carpio, and its ornamental variety, koi. After recent detections of the virus in various countries around the world, KSD has emerged as a new global disease in carp. However, the prevalence of the infection in carp populations in a given geographical region has not been studied thoroughly. The present communication reports an investigation into the presence of CEV in carp and koi populations in Germany. For this purpose, gill samples collected from carp and koi populations suffering from gill diseases or collected for a routine examination of their health status were tested for the presence of CEV by PCR. In total, 651 fish samples from 401 carp or koi cases were examined in 2015 and 2016, additional 118 samples from previous studies were included in the examination. CEV was detected in archive samples from carp dating back to 2007, and in koi samples dating back to 2009. From 2015 to 2016, CEV was detected in 69% of cases from carp populations examined from the main carp-producing areas in Germany, and in 41% of the examined cases from koi populations from all over Germany. Clinical KSD occurred mainly from April to June in carp populations at water temperatures ranging from 8 to 12°C and in koi populations at water temperatures ranging from 18 to 22°C. Most fish from clinically affected carp or koi populations harboured high virus loads of above 10,000 copies of CEV-specific DNA per 250 ng DNA, while gills from fish of other fish species from the ponds, including goldfish, grass carp and European perch were found CEV negative or harboured a low virus load. A phylogenetic analysis revealed the presence of multiple CEV variants from genogroup I in carp and genogroup II in koi populations in Germany. Genetically identical genogroup I isolates were detected in carp from different geographical locations in Germany and in other European carp populations. Some German genogroup II variants were identical to variants previously recorded from koi in Asian and other European countries. The data presented here show that CEV is highly prevalent in German common carp and koi populations and implies the spreading of this virus by intense trading of common carp and koi without necessary risk mitigating measures. As infections with this virus may induce serious disease, CEV diagnostic should be included in health surveillance and disease monitoring programmes.

Validation of a KHV antibody enzyme-linked immunosorbent assay (ELISA)

Koi herpesvirus (KHV) causes KHV disease (KHVD). The virus is highly contagious in carp or koi and can induce a high mortality. Latency and, in some cases, a lack of signs presents a challenge for virus detection. Appropriate immunological detection methods for anti-KHV antibodies have not yet been fully validated for KHV. Therefore, it was developed and validated an enzyme-linked immunosorbent assay (ELISA) to detect KHV antibodies. The assay was optimized with respect to plates, buffers, antigens and assay conditions. It demonstrated high diagnostic and analytical sensitivity and specificity and was particularly useful at the pond or farm levels. Considering the scale of the carp and koi industry worldwide, this assay represents an important practical tool for the indirect detection of KHV, also in the absence of clinical signs.

Draining and liming of ponds as an effective measure for containment of CyHV-3 in carp farms

Infections of common carp Cyprinus carpio and koi, its coloured morphotypes, with the cyprinid herpesvirus 3 (CyHV-3) can induce severe clinical signs and increased mortality in affected stocks. This may significantly challenge the economic basis of carp farming in Central Europe. To limit virus spread in carp farms, effective disinfection measures for ponds stocked with infected populations are required. In the traditional European pond aquaculture of carp, draining and liming of ponds with quicklime (CaO) up to pH 12 is a well-established disinfection measure against various pathogens. The present field study investigated whether these measures are sufficient for the inactivation of CyHV-3 infectivity in carp ponds. After draining and liming, the ponds were stocked with carp fry from a CyHV-3-negative stock, and 2 ponds were examined for the presence of CyHV-3-specific DNA sequences during the growth period of the carp and in the harvested stock. Wild fish (from the ponds, and feeder and drainage canals) and water samples (from the ponds) were also examined for CyHV-3-specific DNA sequences; and naïve carp were cohabited with wild fish, or exposed to the pondwater samples, to test for the presence of infectious virus. All examined samples remained negative for CyHV-3 throughout the study. This indicates that draining and liming with quicklime can be a suitable disinfection measure for ponds after a CyHV-3 outbreak in carp aquaculture.

Modulation of expression of the nuclear receptor NR0B2 (small heterodimer partner 1) and its impact on proliferation of renal carcinoma cells

Mammalian nuclear receptors (NRs) are transcription factors regulating the expression of target genes that play an important role in drug metabolism, transport, and cellular signaling pathways. The orphan and structurally unique receptor small heterodimer partner 1 (syn NR0B2) is not only known for its modulation of drug response, but has also been reported to be involved in hepatocellular carcinogenesis. Indeed, previous studies show that NR0B2 is downregulated in human hepatocellular carcinoma, suggesting that NR0B2 acts as a tumor suppressor via inhibition of cellular growth and activation of apoptosis in this tumor entity. The aim of our study was to elucidate whether NR0B2 may also play a role in other tumor entities. Comparing NR0B2 expression in renal cell carcinoma and adjacent nonmalignant transformed tissue revealed significant downregulation in vivo. Additionally, the impact of heterologous expression of NR0B2 on cell cycle progression and proliferation in cells of renal origin was characterized. Monitoring fluorescence intensity of resazurin turnover in RCC-EW cells revealed no significant differences in metabolic activity in the presence of NR0B2. However, there was a significant decrease of cellular proliferation in cells overexpressing this NR, and NR0B2 was more efficient than currently used antiproliferative agents. Furthermore, flow cytometry analysis showed that heterologous overexpression of NR0B2 significantly reduced the amount of cells passing the G1 phase, while on the other hand, more cells in S/G2 phase were detected. Taken together, our data suggest that downregulation of NR0B2 may also play a role in renal cell carcinoma development and progression.

Microbiological stability of solutions containing local anesthetics and opioids in closed infusion systems used for epidural analgesia

Nine solutions containing opiod analgesics and local anesthetics as typically use in epidural catheters were tested for antimicrobial stability. Administration via a pefusor syringe requires several refill processes. It was shown that repetitive refilling of the syringes did not result in any microbiological contamination.

Liver X receptor α and farnesoid X receptor are major transcriptional regulators of OATP1B1

Organic anion transporting polypeptide 1B1 (OATP1B1) is a liver-enriched transporter involved in the hepatocellular uptake of many endogenous molecules and several structurally divergent drugs in clinical use. Although OATP1B1 coding region polymorphisms are known to make an impact on substrate drug disposition in humans, little is known regarding the mechanisms underlying the transcriptional regulation of this transporter. In this study, we note that messenger RNA (mRNA) expression of OATP1B1 in a large human liver bank exhibited marked interindividual variability that was not associated with coding region polymorphisms. Accordingly, we hypothesized that such variability in expression is reflective of nuclear receptor-mediated transcriptional regulation of this transporter. We tested prototypical ligands for the nuclear receptors pregnane X receptor (PXR), constitutive androstane receptor (CAR), liver X receptor (LXR) α, and farnesoid X receptor (FXR) in a human hepatoma-derived cell line and noted induction of OATP1B1 mRNA when the cells were treated with LXRα or FXR ligands. To confirm a direct role for LXRα and FXR to OATP1B1 expression, we performed detailed promoter analysis and cell-based reporter gene assays resulting in the identification of two functional FXR response elements and one LXRα response element. The direct interaction between nuclear receptors with the identified response elements was assessed using chromatin immunoprecipitation assays. Using isolated primary human hepatocytes, we show that LXRα or FXR agonists, but not PXR or CAR agonists, are capable of OATP1B1 induction.

CONCLUSION

We note that OATP1B1 transcriptional regulation is under dual nuclear receptor control through the oxysterol sensing LXRα and the bile acid sensor FXR. Accordingly, the interplay between OATP1B1 and nuclear receptors may play an important and heretofore unrecognized role during cholestasis, drug-induced liver injury, and OATP1B1 induction-related drug interactions.

[Extent of resection in surgery of stomach carcinoma]

The extraluminal extent of resection in cases of advanced gastric cancer is controversial. If, however, following meticulous staging--including the detection of free abdominal tumor cells--complete resection seems possible, then multivisceral resection is justified. If complete resection is achieved, the prognosis of these patients can be improved. Left pancreatic resection should be performed only if the tumor invades the pancreas directly. Splenectomy is indicated if the tumor invades the organ directly or if there are locally advanced tumors of the proximal third of the stomach and tumors of the esophageal-gastric junction. However, it has to be kept in mind that splenectomy is an independent negative prognostic factor. The extent of lymphadenectomy (LA) in gastric cancer is still under discussion. According to the 10-year results of the Dutch Gastric Cancer Study, there might be subgroups which have a survival benefit after extended (D2) LA. These include, as the German Gastric Cancer Study corroborated, patients with very early stage II and stage IIIa lymph node metastases. As neither of these stages can at present be diagnosed before or during surgery, D2 lymphadenectomy should be the standard procedure for all patients with gastric cancer. Recent studies have shown that it might be possible with the help of the Sentinel Node Technique to individualize lymphadenectomy in locally gastric cancer as well. The beneficial effects of adjuvant chemoradiation in gastric cancer do not mean, however, that the extent of resection may be reduced. Adjuvant chemoradiation following complete resection and D2 lymphadenectomy should still not be regarded as standard therapy.

[Cecal diverticulitis]

INTRODUCTION

Cecal diverticulitis is an important differential diagnosis to acute appendicitis. The diagnosis is often difficult to make and the therapeutic procedure is still a point of discussion.

PATIENTS AND METHOD

Seven patients (24-77 years old) who underwent surgery for abdominal reasons were investigated retrospectively.

RESULTS

Five patients who had not underwent appendectomy before were operated under the leading diagnosis of acute appendicitis. Despite further diagnostic measures, only in one case of the two patients who had already had an appendectomy before, the diagnosis cecal diverticulitis could be made preoperatively.

DISCUSSION

Preoperative diagnostics, if conducted at all, only rarely lead to the diagnosis of cecal diverticulitis. In prolonged courses and in patients after appendectomy, laparoscopy can be of diagnostic and therapeutic value. If it is possible to diagnose cecal diverticulitis preoperatively, conservative treatment can be indicated. If the diagnosis is made intraoperatively and malignancy can be securely excluded, we recommend ileocecal resection, but not appendectomy and further conservative treatment. If a carcinoma can not be excluded definitively, a hemicolectomy must be performed.

[Telemetric impedance analysis of the liver: evaluation of a noninvasive device for diagnosis of acute graft rejection after experimental liver transplantation]

Allograft rejection and its differentiation from other causes of organ dysfunction remains a diagnostic problem in liver transplant patients. Currently, acute rejection can be prevented only by a combination of diagnostic and therapeutic modalities. The diagnostic potential of a novel implantable telemetric rejection monitoring device has been assessed on the basis of the noninvasive impedance analysis in normal and liver transplanted pigs. The electric impedance data were correlated with biochemical and histological parameters. Acute rejection was correctly predicted in n = 4, and correctly excluded in n = 32, biopsy-related impedance recordings (p = 0.004). A correlation between impedance measurements and severity of histological findings r = 0.84; p = 0.0001) was confirmed. Only the biochemical parameters SGLDH and serum bilirubin revealed a comparable correlation. Impedance gradient analysis revealed evidence of a physiological relationship between liver function and the electrical properties of the organ. Telemetric impedance analysis would appear a promising means of assessing acute rejection noninvasively.

Prognostic factors in gastric stump carcinoma

OBJECTIVE

To compare prognostic results in patients with gastric stump cancer (GSC) versus those with primary gastric cancer (PGC).

SUMMARY BACKGROUND DATA

Gastric stump carcinomas have often been described as having low resectability rates and a poor prognosis.

METHODS

Results of surgical treatment of 50 patients with GSC were compared with that of 516 patients with PGC.

RESULTS

The resectability rate was 94% for GSC patients and 96.5% for PGC patients, without significant differences in terms of postoperative complications, death rate, and median survival time (31.6 vs. 32.9 months). The multivariate analysis showed an independent prognostic effect for R0 resection, pT1 and pT2 category, and age older than 65 years.

CONCLUSION

The prognosis after resection and adequate lymphadenectomy does not differ between patients with GSC and PGC.

[Does the new UICC classification allow better prognostic assessment for ductal pancreatic carcinoma?]

INTRODUCTION

To compare treatment results an international established classification is necessary. In 1997 the TNM classification of 1992 was modified.

METHODS

Between 1983 and 1997, 159 patients with a ductal carcinoma of the pancreas underwent resection. All data of the resected specimens were documented in standardized manner prospectively in a protocol that offered ready transfer of the collected data to a new classification. The TNM categories and stage groupings were transferred to the new UICC classification of 1997 and analyzed in comparison to the classification of 1992.

RESULTS

The inclusion of a pT4 category equivalent to the other GI tumors made a new stage grouping necessary. Also division into pN1 a and pN1 b was established. According to the clinical experience only few tumors in early stages (pT1/2 and stage I) were observed in the new classification. There was a significant improval in the patient's distribution to the new stage grouping because of the homogeneous groups. In comparison to the 1992 classification the new stage II shows a relevant prognostic value and a significant difference to stage III.

CONCLUSION

We conclude that the new UICC classification relates to prognosis better than the old classification.

[Intestinal pouches: gastric reconstruction]

Reconstruction of the intestinal passage after a total gastrectomy is usually based on a direct esophagojejunostomy with end-to-side implantation of the afferent loop. The second principle of reconstruction is based on preservation of the duodenal passage. Long-term problems such as weight loss and malnutrition are further considerations that lead to the concept that gastric reconstruction should have the form of a reservoir. In addition to the construction of the reservoir itself, the clinical concern of avoiding gastroesophageal reflux is a further requirement for the choice of reconstruction type. Diversion of the duodenal content via a Roux-en-Y end-to-side anastomosis is considered to be the standard procedure. Interposition of a sufficiently long duodenal loop with maintenance of the duodenal passage also has the effect of preventing duodenal reflux. A theoretical advantage of this procedure is the linking of the motility of the duodenum with that of the interposed segment with improved synchronization of the aboral nutrient passage. When one considers complicated reconstructive procedures, the present literature suggests construction of a pouch is definitely functionally superior to the simple esophagojejunostomy. Whether the duodenal passage should be maintained or whether a Roux-Y technique should be used is a question that is still open for discussion.

[Prognostic factors of gastrointestinal stromal tumors of the stomach]

The stomach is the most common gastrointestinal site of mesenchymal tumors which traditionally have been designated as smooth muscle tumors. However, with increasing analytic tools most investigators were unable to demonstrate true myogenic differentiation. Furthermore, the biological behavior of gastrointestinal stromal tumors (GIST) is difficult to predict. The aim of this study was to evaluate MIB-1 and p53 as additional prognostic markers, as well as myogenic differentiation immunohistochemically in GIST. 43 gastric stromal tumors were reviewed, 19 were classified as benign, and 10 as malignant. 14 tumors were considered indeterminate for biological behavior. In addition to MIB-1 and p53, immunohistochemistry was also performed for sm-actin, desmin and S 100-protein (ABC). 41 patients had a clinical follow-up of more than 2.5 years, 5 patients had metastases. Mean proliferation rates defined as percentage of MIB-1 positive tumor cells in 3 HPF were as follows: typical leiomyoma: 0.2%; benign GIST, spindle cell type: 1.8%; benign GIST, epithelioid cell type: 2.4%; borderline GIST, spindle cell type: 2.1%; borderline GIST, epithelioid cell type: 2.5%; malignant GIST, spindle cell type: 4.9%; and malignant GIST, epithelioid cell type: 7.3%. All 5 metastasizing tumors had a proliferation index > 4% (p < 0.0001). 4/5 metastasizing tumors had p53 positive cells (p < 0.05). 36/43 tumors were sm-actin positive, 7 of which were positive for desmin as well. Classification of gastric mesenchymal tumors as GIST is appropriate because only a small percentage show true smooth muscle differentiation. A MIB-1 proliferation index above 4% might indicate a more aggressive course, as well as p53 positivity.

Carbonic anhydrase in the gills of seawater- and freshwater-acclimated flounders Platichthys flesus: purification, characterization, and immunohistochemical localization

Flounders Platichthys flesus were investigated with respect to isolation, purification, and cellular localization of carbonic anhydrase (CA) in the respiratory system. CA was purified from gills and erythrocytes and was shown to exclusively represent a soluble enzyme with an apparent molecular weight of 30 kD. Inhibition constants (KI) towards acetazolamide (ACTZ) were 8.4.10(-9) M for erythrocyte CA and 7.6.10(-9) M for gill CA, indicating a high sensitivity to sulfonamides, as exhibited by human CA II. Specific CA activity did not differ significantly in seawater- and freshwater-acclimated fish. Antibodies were raised against purified gill and erythrocyte CA. Both antisera crossreacted and were used to localize CA in the gills of seawater and freshwater flounders at the light microscopic level. Independent of the salinity, a positive reaction of variable intensity was found in the following cell types: pavement cells (PVCs), forming the gill epithelial surface layer; mucous cells (MCs); pillar cells (PCs), bordering the vascular channels of the secondary lamellae; and chloride cells (CCs), mitochondria-rich cells located in the primary epithelium, the interlamellar regions, and at the bases of the secondary lamellae.(J Histochem Cytochem 47:43-50, 1999)

Relevant prognostic factors in gastric cancer: ten-year results of the German Gastric Cancer Study

OBJECTIVE

In 1986 a prospective multicenter observation trial in patients with resected gastric cancer was initiated in Germany. An analysis of prognostic factors based on the 10-year survival data is now presented.

PATIENTS AND METHODS

A total of 1654 patients treated for gastric cancer between 1986 and 1989 at 19 centers in Germany and Austria were included. The resected specimen were evaluated histopathologically according to a standardized protocol. The extent of lymphadenectomy was classified after surgery based on the number of removed lymph nodes on histopathologic assessment (25 or fewer removed nodes, D1 or standard lymphadenectomy; >25 removed nodes, D2 or extended lymphadenectomy). Endpoint of the study was death. Follow-up is complete for 97% of the included patients (median follow-up of the surviving patients is 8.4 years). Prognostic factors were assessed by multivariate analysis.

RESULTS

A complete macroscopic and microscopic tumor resection (R0 resection according to the UICC 1997) could be achieved in 1182 of the 1654 patients (71.5%). The calculated 10-year survival rate in the entire patient population was 26.3% +/- 4.7%; it was 36.1% +/- 1.6% after an R0 resection. In the total patient population there was an independent prognostic effect of the ratio between invaded and removed lymph nodes, the residual tumor (R) category, the pT category, the presence of postsurgical complications, and the presence of distant metastases. Multivariate analysis in the subgroup of patients who had a UICC R0 resection confirmed the nodal status, the pT category, and the presence of postsurgical complications as the major independent prognostic factors. The extent of lymph node dissection had a significant and independent effect on the 10-year survival rate in patients with stage II tumors. This effect was present in the subgroups with (pT2N1) and without (pT3N0) lymph node metastases on standard histopathologic assessment. The beneficial effect of extended lymph node dissection for stage II tumors persisted when patients with insufficient lymph node dissection (<15 nodes) were excluded from the analysis. There was no difference in the postsurgical morbidity and mortality rates between patients with standard and extended lymph node dissection.

CONCLUSIONS

Lymph node ratio and lymph node status are the most important prognostic factors in patients with resected gastric cancer. In experienced centers, extended lymph node dissection does not increase the mortality or morbidity rate of resection for gastric cancer but markedly improves long-term survival in patients with stage II tumors. This effect appears to be independent of the phenomenon of stage migration.

Classification of regional lymph node metastasis from gastric carcinoma. German Gastric Cancer Study Group

BACKGROUND

Classification of lymph node metastasis from gastric carcinoma was based on the localization (International Union Against Cancer/American Joint Committee on Cancer [UICC/AJCC] 1992). The authors analyzed the data of the German Gastric Cancer Study (GGCS) to determine whether the number of involved lymph nodes related to the prognosis independent of their anatomic localization (UICC/AJCC 1997).

METHODS

For 477 patients of the GGCS resected for cure (UICC/AJCC R0 resection) who had involved regional lymph nodes and no evidence of distant metastases, the 1992 UICC/AJCC classification was compared with the new UICC/AJCC classification (1997) based on the number of involved lymph nodes (ILN).

RESULTS

Two hundred fifty-eight patients (54.1%) had 1-6 ILN, 137 patients (28.7%) had 7-15, and 82 patients (17.2%) had more than 15. When the 1992 and 1997 UICC/AJCC classifications were compared, the prognosis of patients classified as pN1 (n = 187) in the 1992 pN classification was homogeneous, whereas there was a marked lack of homogeneity among the patients classified as pN2 (n = 290). For 103 of 290 patients with 1-6 ILN, the prognosis appeared to be more favorable (5-year survival rate, 45.5%), whereas 137 of 290 patients with 7-15 ILN had an intermediate prognosis (5-year survival rate, 29.7%). Eighty-two of 290 patients had a dismal prognosis, with a 5-year survival rate of 10.4%. There was a highly significant difference in survival (P < 0.0001). Within the groups with 1-6, 7-15, and more than 15 ILN, the localization of ILN did not significantly alter the prognosis.

CONCLUSIONS

The UICC/AJCC classification based on the number of involved regional lymph nodes allows for an estimation of prognosis superior to the 1992 classification. In addition, the new classification can now be applied without methodologic problems and seems more reproducible.

[Lymphadenectomy in tumors of the upper gastrointestinal tract]

Similar to other tumor entities, complete tumor removal with an adequate safety margin in all three dimensions (the oral margin, the aboral margins and the tumor bed) must be the primary aim of any surgical approach to carcinoma of the upper gastrointestinal tract. The same goal has to be achieved in the area of the lymphatic drainage. All positive nodes and nodes with a so-called 'microinvolvement' have to be removed together with the primary tumor. The safety margin of lymphadenectomy can be estimated by the lymph node ratio, i.e., the ratio between the number of removed and positive nodes. Several studies have shown that for carcinoma of the upper gastrointestinal tract the prognosis can be improved markedly if the lymph node ratio is below 0.2. For tumors in the early phase of lymphatic metastasis this can be achieved by extensive lymph node dissection. In practice, this requires as a minimum a lymphadenectomy of compartments I and II of the tumor's lymphatic drainage (D2 lymphadenectomy). The individual compartments are determined by the embryogenesis of the affected organ and defined by the tumor location. In patients with advanced lymphatic metastases, lymphadenectomy does not improve the prognosis and can only result in a reduction of local recurrences. Lymphadenectomy does not increase the risk and morbidity of the surgical procedure, provided it is restricted to the removal of nodes. These basic principles of lymphadenectomy are valid for carcinomas of the esophagus, cardia and stomach.

Benefits of D2 lymph node dissection for patients with gastric cancer and pN0 and pN1 lymph node metastases

A retrospective immunohistological analysis of 100 patients with pT1-3 N0 and pT1-3 N1 gastric adenocarcinoma demonstrated a high frequency of micro-involvement in the removed lymph nodes. The presence of three or more tumour cells in more than 10 per cent of the lymph nodes was of significant prognostic value in the pN0 cases. Multivariate analysis identified micro-involvement as an independent prognostic factor. The results explain why patients benefit from lymphadenectomy even if the removed lymph nodes are not involved by tumour (pN0) in routine histological examination. The frequent occurrence of micro-involvement is a strong argument favouring routine D2 lymph node dissection in gastric cancer surgery in patients with lymph node metastasis.

[Comparison of the quality of life after subtotal and total gastrectomy for stomach carcinoma]

OBJECTIVE

To compare quality of life after subtotal gastrectomy (STG) and total gastrectomy of various types, in view of the fact that, with T1 and T2 gastric carcinoma of intestinal type in the distal third of the stomach, subtotal gastrectomy is similar to total gastrectomy regarding the extent of lymphadenectomy and prognosis.

PATIENTS AND METHODS

Quality of life was measured by standardised questionnaires given to 36 patients after subtotal gastrectomy (22 men, 14 women; mean age 63 [27-79] years): general physical complaints (GPC); contentment with life (CL); psychosocial stress (PSS). The results were compared with those previously obtained in 58 patients with total gastrectomy (46 men, 12 women; mean age 63.4 [36-74] years) and oesophagojejunostomy (OJS) (n = 29) or oesophagojejunoplication and pouch (OJPP) (n = 29).

RESULTS

Weight loss of patients after OJPP was not significantly different from that of patients after STG, but it was significantly higher after OJS (13.5 +/- 8.6 kg; P < 0.0006). Patients with STG had significantly more general complaints (P < 0.05) and greater discontent with life (P < 0.05) than those with OJPP. Specific analysis of gastric complaints showed greatest dissatisfaction with gastrointestinal functions in patients after STG (P < 0.0004), less also after OJS compared with OJPP (P < 0.01).

CONCLUSIONS

Subtotal gastrectomy for gastric carcinoma has no advantages over total gastrectomy with oesophagojejunoplication and pouch as regards weight loss, gastrointestinal complaints, psychosocial stress and general contentment. The poor quality of life seems to have its functional correlate in increased intestino-oesophageal reflux with incompetent cardia and after Billroth II reconstruction.

Preoperative chemotherapy for stage III-IV gastric carcinoma: feasibility, response and outcome after complete resection

Despite extensive resection and systematic lymphadenectomy the prognosis of patients with locally advanced gastric carcinoma remains poor. The effect of preoperative outpatient chemotherapy with etoposide, doxorubicin and cisplatin was evaluated prospectively in 30 patients who had been shown by preoperative staging (including endosonography and surgical laparoscopy) to have gastric carcinoma stages IIIA, IIIB or IV. Haematological side-effects were common and necessitated hospitalization in 13 of 30 patients. Complete clinical response to neoadjuvant therapy was observed in eight of 27 evaluable patients. Resection was performed in 27 of 30 patients, with complete macroscopic and microscopic tumour removal in 24. There were no deaths and no major morbidity following operation. On multivariate analysis complete clinical response (P < 0.01) and complete tumour resection (P < 0.01) were the major independent predictors of long-term survival after neoadjuvant chemotherapy. Actuarial survival after complete tumour removal was superior with neoadjuvant therapy compared with results in an age-, sex- and tumour stage-matched control population who had primary resection (P = 0.07). Recurrence occurred in 17 of 23 evaluable patients who had complete tumour removal, with relapse in the tumour bed or area of lymphatic drainage in 11. These data show that neoadjuvant therapy in patients with locally advanced gastric carcinoma is feasible and appears to increase the rate of complete tumour removal. More powerful and less toxic regimens are, however, required to improve the response rate and to delay or avoid recurrence after neoadjuvant chemotherapy.

Lymphadenectomy for gastric cancer in clinical trials: update

The controversy over the value of extended lymph node dissection for treatment of gastric cancer is fiercely debated. Whereas Japanese surgeons claim that the superior survival rates in their series are due to extensive resection (D2 resection), many Western authorities believe that their results only reflect differences in the prevalence of prognostic factors, inconsistencies between Japanese and Western staging systems, and the phenomenon of "stage migration," which occurs with extensive resection. Two small randomized prospective trials from Hong Kong and Cape Town showed a tendency toward high morbidity with extensive lymph node dissection but no survival benefit. In contrast, the recently completed prospective German Gastric Carcinoma Study demonstrated a clear survival advantage with D2 resection for tumor stages II and IIIa with no increase in perioperative morbidity or mortality. The long-term results of the still ongoing randomized MRC and Dutch trials are therefore eagerly awaited.

Problem of proximal third gastric carcinoma

The prevalence of proximal third gastric carcinoma increases rapidly in the Western world. An analysis of prognostic factors indicates that the poor prognosis usually associated with these tumors is due at least in part to late presentation and advanced tumor stages. The current TNM classification usually understages these tumors because it does not take the partly retroperitoneal location of the proximal stomach into account. After correction of the TNM classification a proximal tumor location has no influence on survival. Because these tumors benefit most from radical lymph node dissection, the retroperitoneal lymphatic drainage must be taken into account when performing lymphadenectomy for proximal third gastric cancer. To avoid pancreatic fistulas and the associated morbidity, a pancreas-preserving splenectomy and lymphadenectomy should be adapted if an extended lymph node resection of the retroperitoneum is performed. Because of the high prevalence of "intestinal type" tumors in the proximal third of the stomach the extent of the luminal resection margins can be limited; that is, a total gastrectomy with transhiatal resection of the distal esophagus usually suffices to achieve complete tumor removal at the oral margin.

Low resolution DNA typing of the HLA-B5 cross-reactive group by nested PCR-SSP

We have established a DNA typing system for the HLA-B5 serologically cross-reactive group (CREG) by means of a two-step PCR amplification with nested sequence-specific primers (nPCR-SSP). The present study provides a low resolution definition of the HLA-B5 CREG, i.e. identifying polymorphism equivalent to serology. Two different primer combinations allow group-specific amplification of all HLA-B5 CREG alleles and other related HLA class I alleles from genomic DNA. The amplified DNA is subjected to a second amplification step using eleven nested primer pairs. This assay permits the detection of the HLA-B5 CREG specificities B35, B51, B52, B53, and B7801 in all homozygous and heterozygous combinations. Sensitivity and specificity as judged by a blind quality control study investigating a reference panel (n = 50) is 100%. Extension of this approach should allow rapid DNA typing of all serologically defined HLA-B specificities by nPCR-SSP.

Membrane-associated carbonic anhydrase from the crab gill: purification, characterization, and comparison with mammalian CAs

Carbonic anhydrase (CA) was purified from the gills of the shore crab Carcinus maenas using affinity chromatography and HPLC. The predominantly membrane-bound CA was found to share several features with mammalian CA IV. Its apparent molecular weight of 36 kDa was reduced to 33 kDa by treatment with PNGase F, suggesting that crab CA is a glycoprotein with one N-linked oligosaccharide chain. More than half of the membrane-bound crab CA was released from membranes by treatment with a phosphatidylinositol-specific phospholipase C, indicating that the branchial CA is anchored to membrane surfaces by a phosphatidylinositol-glycan linkage. The enzyme also resembles mammalian CA IV in its relative sensitivity to inhibition by sulfonamides and the resistance to inhibition by halide ions. Amino acid composition of the HPLC-purified crab CA was examined and CNBr cleavage was carried out followed by N-terminal amino acid sequencing. Amino-terminal sequence of the native enzyme differed considerably from those of mammalian isozymes (human CA I and CA II, bovine CA III, human and rat CA IV). However, antisera raised against rat CA IV, CA II, and CA I all cross-reacted weakly with crab CA. Unlike mammalian CA IVs, crab gill CA was sensitive to 0.2% sodium dodecyl sulfate, suggesting that although crab gill CA is like mammalian CA IVs in many ways, it is less stabilized by intramolecular disulfide bonds.

[Risk of surgical therapy of stomach cancer in Germany. Results of the German 1992 Stomach Cancer Study. German Stomach Cancer Study Group ('92)]

The German Gastric Cancer Study (GGCS '92) permits a representative pictures of the current situation in surgery for gastric carcinoma at university centers in Germany. The analysis of frequency of resection, complication rate and mortality provides a quality measure for anybody who performs surgical therapy for gastric carcinoma. The results of multivariate analyses will have therapeutic consequences.

Prognostic factors in gastric carcinoma. Results of the German Gastric Carcinoma Study 1992

BACKGROUND

The impact of patient- and tumor-dependent factors and the postoperative course on the prognosis of patients who underwent resection for gastric carcinoma between 1986 and 1989 were analyzed in a prospective multicenter observation study.

METHODS

Resection techniques, the extent of lymph node dissection, and the histopathologic assessment of the specimen were standardized at all participating centers. A total of 1654 patients were enrolled. Follow-up is complete for 99.2% of the patients, with a median follow-up time of 48 months. Prognostic factors were assessed by multivariate analysis.

RESULTS

In the total patient population there was an independent prognostic effect of nodal status, a International Union Against Cancer (UICC)-R0 resection, distant metastases, the pT category, three or more risk factors on preoperative risk analysis, and the presence of postoperative complications. Multivariate analysis in the subgroup of patients who had a UICC-R0 resection confirmed the nodal status as the major independent prognostic factor.

CONCLUSION

These data suggest that the prognosis of patients who undergo gastrectomy for gastric carcinoma may be improved by a complete resection of the primary tumor and its lymphatic drainage, resulting in a UICC-R0 resection. In addition, a detailed preoperative risk analysis and identification of high-risk patients and meticulous attention to the technical details of the surgical procedure to reduce the frequency of postoperative complications may improve the prognosis.

Prognostic factors in gastric carcinoma. Results of the German Gastric Carcinoma Study 1992

BACKGROUND

The impact of patient- and tumor-dependent factors and the postoperative course on the prognosis of patients who underwent resection for gastric carcinoma between 1986 and 1989 were analyzed in a prospective multicenter observation study.

METHODS

Resection techniques, the extent of lymph node dissection, and the histopathologic assessment of the specimen were standardized at all participating centers. A total of 1654 patients were enrolled. Follow-up is complete for 99.2% of the patients, with a median follow-up time of 48 months. Prognostic factors were assessed by multivariate analysis.

RESULTS

In the total patient population there was an independent prognostic effect of nodal status, a International Union Against Cancer (UICC)-R0 resection, distant metastases, the pT category, three or more risk factors on preoperative risk analysis, and the presence of postoperative complications. Multivariate analysis in the subgroup of patients who had a UICC-R0 resection confirmed the nodal status as the major independent prognostic factor.

CONCLUSION

These data suggest that the prognosis of patients who undergo gastrectomy for gastric carcinoma may be improved by a complete resection of the primary tumor and its lymphatic drainage, resulting in a UICC-R0 resection. In addition, a detailed preoperative risk analysis and identification of high-risk patients and meticulous attention to the technical details of the surgical procedure to reduce the frequency of postoperative complications may improve the prognosis.

Prognostic relevance of systematic lymph node dissection in gastric carcinoma. German Gastric Carcinoma Study Group

In a prospective multicentre study of 2394 patients with gastric carcinoma the prognostic relevance of systematic lymph node dissection was evaluated. Of 1654 patients undergoing resection, 558 had a standard lymph node dissection, defined as fewer than 26 nodes in the specimen, and 1096 underwent radical lymphadenectomy, i.e. 26 or more nodes in the specimen. Radical dissection significantly improved the survival rate in patients with Union Internacional Contra la Cancrum (UICC) stages II and IIIA tumours. Multivariate analysis identified radical dissection as an independent prognostic factor in the subgroups of patients with UICC tumour stages II and IIA. Radical dissection conferred no survival advantage in patients with pN2 tumours. There was no significant difference in morbidity and mortality rates between radical and standard lymph node dissection. Radical lymphadenectomy improves survival in patients with UICC gastric cancer stages II and IIIA, and should be the recommended treatment for such patients.

[The epidemiology of stomach carcinoma from the surgical viewpoint. The results of the German Stomach Carcinoma Study 1992. The German Stomach Carcinoma Study Group]

In a prospective multi-centre study data were collected on 1,999 patients (1273 men, 726 women; mean age 62.3 [19-99] years) with gastric carcinoma, admitted to one of 19 surgical departments in Germany between 1.4. 1986 to 30. 6. 1989. Previously treated patients as well as those with synchronous or metachronous tumours and carcinoma of the gastric stump had been excluded. The resection rate for gastric carcinoma was 82.7%, i.e. resection was no longer possible because of the advanced tumour stage in nearly 20%. The tumour was located in the upper third of the stomach in 30%, the antrum in 26.3%. An intestinal type of growth was present in 51.9%. An early carcinoma was diagnosed in 16.9% of operated patients; it had already metastasized to regional lymph nodes in 16.5%. Nearly 70% of patients with resectable tumours had metastases to the regional lymph-nodes, with distant metastases in 30%. An advanced tumour stage (UICC stage IIIB or IV) was present in 43%. Exclusively surgical treatment is not effective in these cases.