C. Ulmer

Impact of miniprobe ultrasonography on planning of minimally invasive surgery for gastric and colonic tumors.

BackgroundThe use of minimally invasive procedures for the management of gastrointestinal cancer is increasing. The aim of this study was to investigate the role of high-frequency miniprobe endoscopic ultrasound (EUS) for therapeutic decisions making in patients with gastric or colonic tumors.MethodsA total of 137 patients underwent EUS with a 12.5-MHz miniprobe for preoperative staging of tumors of the stomach (n = 49) or colon (n = 88). After resection, the surgical path was reviewed to analyze the role of preoperative staging with miniprobes.ResultsMiniprobe EUS enabled accurate assessment of the infiltration depth of gastric and colonic tumors. The overall accuracy rates were 88% and 87%, respectively. The lymph node status was predicted correctly in 82% of the patients (sensivity, 61%, specificity, 94%). Based on the results of miniprobe EUS, patients with gastric cancer were accurately selected to undergo endoscopic mucosal resection, laparoscopic resection, or open surgery in 100%, 91%, and 86% of the cases, respectively. In patients with colonic tumors, the treatment decision analysis showed that the stratification was correct in 90% of the patients.ConclusionsMiniprobe EUS is a reliable method for validating treatment decisions for patients undergoing minimally invasive procedures for gastric and colonic tumors. This method is particularly valuable in the management of colon cancer, because endoscopic and laparoscopic resections can be offered to selected patients as an alternative to open surgery.

Endosonography of upper gastrointestinal tract cancer on demand using miniprobes or endoscopic ultrasound.

Background: The aim of this study was to investigate whether endosonography on demand with miniprobes and conventional endoscopic ultrasound improves the accuracy of endosonographic staging of upper gastrointestinal tract cancer. Methods: Altogether, 173 patients underwent endoscopic ultrasonography for preoperative staging of esophageal (n = 63) or gastric cancer (n = 110). Depending on the endoscopic appearance (i.e., size and growth pattern), tumors were examined with a linear-array echoendoscope (7.5 MHz) or with high-resolution miniprobes (12.5 MHz). The results of preoperative staging were correlated with histopathology of the resection specimen. Results: The overall accuracy of miniprobe ultrasonography and endoscopic ultrasound in assessing the infiltration depth of upper gastrointestinal cancer was 87% and 81%, respectively. Miniprobe ultrasonography was superior to conventional endoscopic ultrasound in the staging of early cancers, particularly T1 tumors (accuracy, 81% vs 56%). The combined accuracy of both techniques for all tumor stages was 82%. Correct diagnosis of lymph node involvement was obtained with miniprobe ultrasonography or endoscopic ultrasound in 76% and 71% of the cases, respectively. The combined accuracy in assessing the lymph node status was 73% (sensitivity, 68%; specificity, 81%). Conclusions: Endosonography on demand using either miniprobes or conventional endoscopic ultrasound may result in more effective and less invasive staging of esophageal and gastric cancer. Selective use of high-resolution miniprobes and conventional endoscopic ultrasound offers accurate staging of all tumor stages.

Refined staging by sentinel lymph node biopsy to individualize therapy in anal cancer

We evaluated the feasibility of the sentinel lymph node technique to refine staging and potentially individualize therapy for anal cancer. Seventeen patients with cancer of the anal canal underwent peritumoral injection of99mTc-colloid, followed 17 hours later by lymphoscintigraphy. A selective lymph node biopsy (SLNB) was attempted in 12 of 13 cases with scintigraphically detected SLNs. Lymph node metastases were present in 5 of 12 cases (42%); in 2 of these 5 cases, micrometastases were detected only by immunohistochemical staining. Hence, SLNB refines the diagnostic workup for anal cancer and provides an accurate basis for individualized therapy.

Prospective comparison of transcutaneous 3-dimensional US cholangiography, magnetic resonance cholangiography, and direct cholangiography in the evaluation of malignant biliary obstruction

BACKGROUND The purpose of this study was to investigate the ability of transcutaneous three-dimensional US cholangiography to depict the biliary tree in malignant obstruction, compared with that of MRCP and direct cholangiography. METHODS Three-dimensional US and MRCP and direct cholangiography were performed in 40 patients with suspected malignant biliary obstruction. Diagnostic quality of the images, presence, level, and cause of ductal obstruction were assessed in a prospective, blinded fashion. The results were correlated with consensus interpretation (3 investigators), intra-operative findings, and histopathology or clinical follow-up. RESULTS Three-dimensional US produced cholangiographic images of diagnostic quality. The appearance of these images was similar to that of MRCP or ERCP/percutaneous transhepatic cholangiography images. All modalities were highly sensitive in the detection of biliary dilatation. The accuracy of 3-dimensional US, MRCP, and ERCP/percutaneous transhepatic cholangiography in determining the level of obstruction was, respectively, 92%, 95%, and 98%. Transcutaneous 3-dimensional US and MRCP accurately identified the cause of obstruction in, respectively, 90% and 95% of cases. Direct cholangiography revealed the correct diagnosis in 95% of the patients. CONCLUSIONS Three-dimensional US cholangiography is a new, noninvasive method with the capability to produce diagnostic cholangiograms. Three-dimensional US cholangiography may be used increasingly as an initial test to select patients who require further diagnostic evaluation by MRCP or therapeutic ERCP.

Sentinel Node Biopsy in Anal Cancer – a Promising Strategy to Individualize Therapy

Background: In order to individualize the therapy in patients with anal cancer, we evaluated the applicability of the sentinel lymph node (SLN) concept for the staging of inguinal lymph nodes in these patients. Patients and Method: SLN mapping using the radiocolloid technique was performed in 12 patients with histopathologically proven anal cancer. Mean age of the 4 male and 8 female patients was 62 years (range: 37–83 years). All patients underwent injection of 99mTc-colloid (Nanocis©) in 4 portions around the tumor followed by scintigraphy after 17 h and selective lymph node biopsy in case of nuclide enrichment. The nuclide-enriched lymph node was intraoperatively identified by a hand-held γ-camera. Histopathological assessment of the harvested SLNs included serial sections and immunohistochemical staining. Results: Enrichment of radiocolloid in lymph nodes was seen in 10 of the 12 patients (detection rate: 83%). SLN biopsy was performed in 9 patients, one patient refused the SLN biopsy (SLNB). 4 patients revealed tumor-infiltrated sentinel lymph nodes including one patient with bilateral biopsy, who showed metastases unilaterally. The remaining 5 patients had no evidence of metastases in the excised SLNs. Conclusion: It is feasible to evaluate the nodal status of the groin in patients with anal cancer using the radiocolloid technique. Preliminary results indicate a refined diagnostic work-up for anal cancer patients, potentially improving the results of clinical and sonographical examinations. Further application of the method may lead to an individualized treatment of patients with anal cancer.

Synovial sarcoma of the extremities. Results of surgical and multimodal therapy

AbstractBackground. Synovial sarcoma is a rare tumor frequently occurring in adolescents and young adults.The preferred location, at the distal parts of the extremities, and the high incidence of distant metastases represent major challenges for treatment.The purpose of this study is to analyze the indications for surgery in the context of a multimodal therapy. Patients and Methods. Between October 1992 and December 2000, 41 patients were treated surgically for synovial sarcoma of the extremities. Their mean age was 35 years (range: 11-75 years).Extracompartmental tumor growth was present in more than 90% of the patients. Fourteen patients (34%) presented with a tumor size of less than 5 cm (T1) while 27 patients (66%) showed lesions greater than 5 cm (T2).At the time of presentation, seven patients had distant metastases; three located in the lung and four in lymph nodes. Results. Due to a locally unresectable tumor or synchronous distant metastases, 28 patients (68%) underwent preoperative systemic chemotherapy (n=9) or isolated limb perfusion (n=18) or both (n=1). In 29 patients, limb-conserving surgery was possible.Of the 12 patients (29%) who required amputation, 85% had a distal tumor.Sixteen patients received additional postoperative radio- and/or chemotherapy. After a median follow-up of 30 months, only two patients (7%) had developed a local recurrence, while seven patients (20%) suffered from new, distant metastases.The 5-year overall survival rate was 82%. Conclusion. With a combined modality treatment, it is possible to achieve excellent local control rates and long-term survival in patients with synovial sarcoma of the extremities.Neoadjuvant treatment can enable limb-sparing surgery in most patients, even if the tumors are located in anatomically difficult areas.ZusammenfassungHintergrund. Dargestellt werden die eigenen Erfahrungen chirurgischer Therapie des Synovialsarkoms im Rahmen eines multimodalen Behandlungkonzeptes. Patienten und Methoden. Es wurden 41 Patienten mit einem Synovialsarkom im Extremitätenbereich operativ behandelt. In 90% der Fälle bestand ein extrakompartmentales Tumorwachstum.Bei 3 Patienten lagen synchrone,hämatogene und bei 4 Patienten synchrone, lymphogene Metastasen vor.Die Nachuntersuchungszeit beträgt im Median 30 Monate. Ergebnisse. Insgesamt konnten 29 der 41 Patienten extremitätenerhaltend operiert werden.Bei 12/41 erfolgte eine Amputation.Bei 28/41 Patienten wurde die Indikation zur präoperativen Therapie gestellt. Eine postoperative Behandlung wurde bei 16/41 Patienten durchgeführt.Bei 2 Patienten kam es zu einem lokalen Tumorrezidiv. Eine hämatogene Metastasierung trat bei 7 der 34 primär nicht metastasierten Patienten auf.Eine erneute lymphogene Metastasierung ließ sich bisher nicht nachweisen. Die 5-Jahres-Überlebensrate beträgt 82%. Schlussfolgerung. Unsere Analyse unterstreicht die Bedeutung eines multimodalen Therapiekonzeptes.Insbesondere wenn durch ein primär operatives Verfahren eine R0-Resektion ohne Amputation nicht sicher zu erreichen ist, sehen wir die Indikation zu einer präoperativen Zusatz-Therapie.

Sentinel lymphonodectomy in gastrointestinal cancer: Where are we now?

Up to now, no reliable methods for the pre- or intraoperative prediction of the nodal status are available in gastrointestinal cancer patients. Therefore, after the successful application of the sentinel lymph node concept in melanoma and breast cancer, ongoing research on this field is extended to gastrointestinal tumor entities. According to recent experiences, the most promising tumor entities are colon, gastric and anal cancer. First results with these patients indicate that the method could be a reliable predictor of the nodal status and, thus, may have important future implications for adjuvant therapy and the extent of surgery. The dye method for colon cancer and the combined method (dye and radiocolloid) for gastric cancer seem to be appropriate approaches, even when the general experience is still low. In rectal cancer, however, current experience failed yet to yield satisfying results. Up to now, anal cancer has not been a focus of publication, even when the concept seems to be very attractive for the evaluation of the inguinal lymph node status.

Optimization of staging in colon cancer using sentinel lymph node biopsy

ZusammenfassungDie standardisierte Erfassung des Lymphknotenstatus beim Kolonkarzinom hängt sehr stark von der individuellen Qualität der histopathologischen Untersuchung und der chirurgischen Technik der Lymphknotendissektion ab. Wir haben geprüft, inwieweit die Anwendung der Sentinel-Lymphknoten-Biopsie (SLNB) zu einer Verbesserung des Lymphknotenstagings beitragen kann.Bei 38 der insgesamt 45 Patienten wurde(n) ein oder mehrere Sentinel-Lymphknoten detektiert (Detektionsrate: 84%). Von diesen 38 Patienten wiesen 10 in der HE-Färbung Lymphknotenmetastasen auf (26%), davon 6 im SLN. Bei 9 der 28 initial in der HE-Färbung als nodal negativ eingestuften Patienten fanden sich mit Hilfe der immunhistochemischen (IHC-)Untersuchung 1 Mikrometastase und in 8 Fällen isolierte Tumorzellen im SLN (32% „Upstaging“). Die IHC-positiven Fälle mit eingerechnet waren damit 19 der 38 Patienten nodal positiv (50%), 15 davon wiesen im SLN Tumorzellen auf (Overall-Sensitivität: 79%).Die SLNB mit Hilfe der Farbstofftechnik ist klinisch praktikabel und führt in der Mehrzahl der Patienten zur Detektion eines SLN. AbstractRoutine 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.

Sentinel-Lymphknoten-Biopsie bei Tumoren des Gastrointestinaltrakts

Bis heute steht keine zuverlässige Methode für die prä- bzw. intraoperative Vorhersage des Lymphknotenstatus bei Patienten mit gastrointestinalen Tumoren zur Verfügung. Nach der erfolgreichen Etablierung der Sentinel-Lymphknoten-Biopsie (SLNB) bei Melanom- und Brustkrebserkrankungen werden weiterführende Untersuchungen auf diesem Gebiet nun auf gastrointestinale Tumorerkrankungen ausgedehnt. In Übereinstimmung mit aktuellen Ergebnissen stellen Darm- und Magenkarzinome vielversprechende Entitäten für das SLN-Konzept dar. Erste Ergebnisse zeigen, dass die Methode zuverlässig den Lymphknotenstatus erfasst und damit in Zukunft vermehrt Einfluss auf adjuvante Therapiekonzepte bzw. auch auf das chirurgische Resektionsausmaß nehmen wird. Zwei Methoden stehen für die SLNB zurzeit zur Verfügung: die Farbstoffmethode und die Radiokolloidmethode. Welche Methode für die jeweilige Tumorentität am sinnvollsten ist und welche Ergebnisse derzeit hiermit erzielt werden, soll nachfolgend erörtert werden.

Optimierung des Staging beim Kolonkarzinom durch Sentinel-Lymphknoten-Biopsie

ZusammenfassungDie standardisierte Erfassung des Lymphknotenstatus beim Kolonkarzinom hängt sehr stark von der individuellen Qualität der histopathologischen Untersuchung und der chirurgischen Technik der Lymphknotendissektion ab. Wir haben geprüft, inwieweit die Anwendung der Sentinel-Lymphknoten-Biopsie (SLNB) zu einer Verbesserung des Lymphknotenstagings beitragen kann.Bei 38 der insgesamt 45 Patienten wurde(n) ein oder mehrere Sentinel-Lymphknoten detektiert (Detektionsrate: 84%). Von diesen 38 Patienten wiesen 10 in der HE-Färbung Lymphknotenmetastasen auf (26%), davon 6 im SLN. Bei 9 der 28 initial in der HE-Färbung als nodal negativ eingestuften Patienten fanden sich mit Hilfe der immunhistochemischen (IHC-)Untersuchung 1 Mikrometastase und in 8 Fällen isolierte Tumorzellen im SLN (32% „Upstaging“). Die IHC-positiven Fälle mit eingerechnet waren damit 19 der 38 Patienten nodal positiv (50%), 15 davon wiesen im SLN Tumorzellen auf (Overall-Sensitivität: 79%).Die SLNB mit Hilfe der Farbstofftechnik ist klinisch praktikabel und führt in der Mehrzahl der Patienten zur Detektion eines SLN. AbstractRoutine 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.