Christian Wittekind

Organ-sparing treatment of advanced bladder cancer: A 10-year experience

PURPOSE Radical cystectomy is considered as standard therapy for muscle-invasive bladder cancer. We present 10-year results of bladder-sparing treatment by conservative surgery and radiotherapy +/- chemotherapy. METHODS AND MATERIALS From 1982 through 1991, 245 consecutive patients, mean age 66 years, with invasive bladder cancer (T2-3 or poor prognostic T1, no distant metastases) entered a prospective protocol with the objective of bladder preservation. Treatment consisted of transurethral resection (complete, if possible) and definitive radiotherapy with 56 Gy maximum dose (50.4 Gy minimum target dose) in 28 fractions. Since 1985, 139 patients received a simultaneous chemotherapy on 5 days in the first and fifth treatment week with either 25 mg/m2 cisplatin daily (79 patients) or 65 mg/m2 carboplatin (60 patients). Cystectomy was performed as salvage treatment for residual or recurrent invasive disease. The median follow-up at the date of analysis (12-31-92) was 5.9 years. RESULTS The overall survival was 47% after 5 years and 26% after 10 years. The 5-year survival according to the initial T-category was 60% for T1 (44 patients), 64% for T2 (47 patients), 43% for T3 (127 patients), and 16% for T4 (23 patients). The most important single prognostic factor was the amount of residual tumor after TUR (5-year survival 80% after R0, 53% after R1, and 31% after R2 resection, p < 0.01). Chemotherapy increased the rate of complete remission, but had no impact on 5-year survival (52% vs. 50%). Fifty-three salvage cystectomies were performed, all without severe complications, and 192 patients (79%) maintained a normal functioning bladder. The bladder preservation rate in 5-year survivors was 83%. CONCLUSIONS Organ-sparing treatment of advanced bladder cancer by transurethral surgery and definitive radiotherapy or radiochemotherapy is feasible and effective. The survival in this series is as good as in any comparable cystectomy series. Eighty-three percent of long-term survivors maintained their functioning bladders.

Prospective multicenter study of the quality of oncologic resections in patients undergoing laparoscopic colorectal surgery for cancer

PURPOSE: Laparoscopic colorectal surgery for cancer is currently under discussion. Results of large, randomized studies will not be available for a number of years yet. This study analyses the results of such resections in consecutive patients operated on by unselected surgeons. METHODS: A prospective, observational, multicenter study was initiated on August 1, 1995, in the German-speaking countries of Europe. One year after initiation of the study, findings are presented with respect to the quality of oncologic resections. RESULTS: Of 500 operations, 231 (46 percent) were performed for cancer, 167 (33 percent) with a curative intent. The most common curative resections were as follows: 63 anterior rectum resections (38 percent), 51 sigmoid resections (30 percent), and 27 abdominoperineal resections (16 percent). Segmental resections were performed in 20 patients (12 percent). Intraoperative tumor spillage was reported in 2 percent. Mean number of lymph nodes harvested was 13 (confidence interval, 5–95 percent; range, 11.5–14.6) and positive lymph nodes harvested was 2.2 (confidence interval, 5–95 percent; range, 0.9–3.4). Significant differences were noted between participating centers in terms of number of lymph nodes resected (P<0.0001). Distal and proximal resection margins were tumorfree in every case. Lateral margins were tumor-free when examined. In the case of 63 curative anterior resections, the mean distal resection margin was 39 (confidence interval, 5–95 percent; range, 33–45) mm, and in 8 of these resections, it was less than 20 mm. Mean blood loss was 344 (confidence interval, 5–95 percent; 292–396) ml, and 21 percent of patients received blood transfusions. CONCLUSIONS: These data document that the average quality of laparoscopic colorectal procedures for cancer is satisfactory but differs among surgeons.

Expression of nm23-H1 predicts lymph node involvement in colorectal carcinoma

PURPOSE: Reduced expression of the metastasis suppressor gene nm23-H1 has previously been correlated with high tumor metastatic potential and fatal clinical outcome in some tumors (e.g.,breast). For colorectal carcinomas, the findings are equivocal. METHODS: We have used a monoclonal antibody against nm23-H1 to investigate the expression in colorectal carcinomas at the time of primary curative surgery (RO resection) to assess if there was any relation between nm23-H1 expression and stage or histologic grade at the time of primary tumor removal. RESULTS: Of 100 colorectal carcinomas studied (Stages I, II, and III according UICC, all resected curatively), nm23-H1 immunoreactivity was weak in 41 (41 percent), moderate in 24 (24 percent), and strong in 35 (35 percent) cases. The grade of positivity against nm23-H1 was significantly lower in advanced stages of the disease (Stages II or III) (P <0.001, chi-squared=52.8). In tumors with low or weak immunoreactivity against nm23-H1, frequency of lymph node metastases was significantly higher compared with those with moderate or strong staining (P <0.001; chi-squared=50.58). Therefore, with a sensitivity of 93 percent and a specificity of 58 percent, low nm23-H1 immunoreactivity of the primary tumor, assessed at the time of surgery, is an indicator of the presence of lymph node metastases. CONCLUSIONS: Immunohisto-chemical evaluation of nm23-H1 in the primary tumor or in a biopsy is a useful predictor of stage of disease and presence of lymph node metastases in colorectal carcinomas and may have clinical significance,e.g.,in predicting optimal therapeutic regimes.

Laparoscopic sigmoid resection for cancer: Curative resection and preliminary medium-term results

PURPOSE Despite reservations about compliance with oncologic radical criteria, laparoscopic resection of the sigmoid colon is increasingly being used with curative intent in oncologic surgery of the colorectum. The aim of the present study was to obtain further information on the perioperative course, the oncologic radicalness of the procedure, and medium-term outcome. METHODS The data presented here were obtained from a prospective, multicenter study conducted in Germany and Austria. These data were acquired from an analysis of subgroups derived from a total of 3,133 recruited patients. RESULTS A total of 292 patients from 36 hospitals underwent laparoscopic resection of the sigmoid colon with curative intent. The definitive histopathologic work-up of surgical specimens revealed the following International Union Against Cancer tumor stages: 122 Stage I, 86 Stage II, and 84 Stage III. The mean operating time was 172 minutes, and the mean intraoperative blood loss was 241 ml. The conversion rate to open surgery was 5.5 percent, the majority of such conversions being made necessary by vascular lesions. Sixty-five of the patients reported at least one postoperative problem or complication (22.3 percent); the mortality rate was 2.7 percent. With a mean of 13.4 recovered lymph nodes and a mean aboral safety margin of 72 mm, the formal criteria for the assessment of oncologic radicalness were met. Intraoperative cell dissemination occurred in two patients. The long-term results, which, at a mean follow-up of 2.1 years and a follow-up rate of 73.3 percent, must be considered preliminary, show a calculated stage-related survival rate of 88.8, 90.9, and 64.1 percent, respectively, for the International Union Against Cancer Stages I, II, and III. CONCLUSIONS Laparoscopic sigmoid resection can be performed technically reliably—also with curative intent—with acceptable complication and mortality rates and, to date, with survival rates that are at least comparable with those achieved with open surgical procedures.

Histological Typing and Grading of Gastric Carcinomas

The aim of a tumor classification is to arrange tumors into specifically defined groups and subgroups. The tumors comprising one group are not usually replicas of each other, but resemble one another more closely than they resemble those in other groups. Such a system is convenient, but has inherent limitations which must be clearly recognized. The pathologist must be aware of the difficulties in the classification of tumors, including gastric carcinomas. Individual tumors exhibit a wide range of structures and behavior, so that subdivisions within groups are largely arbitrary.

Cholestasis Induced by Hyperthyroidism after Liver Transplantation

We report the case of a 68-year-old woman who underwent liver transplantation because of hepatitis-C-induced cirrhosis. She developed iodine-reduced hyperthyroidism postoperatively in temporal relation with cholestatic jaundice. Hepatic biopsies revealed moderate intrahepatic cholestasis and mild lobular inflammatory infiltration with some eosinophils. No histological evidence of acute graft rejection or reactivated hepatitis was found. Treatment with methimazole markedly reduced the serum parameters of cholestasis which, after subtotal thyroidectomy, returned to normal. Liver function recovered, as confirmed by repeated aminopyrine breath tests.

Surgical removal of a lipoma of the heart

In a 29-year-old woman echocardiography revealed a tumour originating from the anterior wall of the right ventricle. Noninvasive findings aroused suspicion of a lipoma. The tumour was removed under cardiopulmonary bypass, the resulting defect in the right ventricular wall being covered with a Goretex patch. Histological examination classified the tumour as a rhabdomyolipoma.

Das Leiomyosarkom des Ösophagus

ZusammenfassungDas Leiomyosarkom des Ösophagus ist ein, seltener Tumor mesenchymalen Ursprungs. Anhand eines Falles wird die klinische Symptomatik und das diagnostische Vorgehen dargestellt sowie auf Therapie und Pathohistologie eingegangen. Primäre gastrointestinale Sarkome stellen weniger als 0,5% aller Ösophagusmalignome dar, sie befallen die Speiseröhre in etwa 5%. Die höchste Inzidenz liegt in der vierten und fünften Lebensdekade. Die Tumoren sind submukös lokalisiert und betreffen die, muskulären Wandschichten überwiegend im mittleren und distalen Anteil des Ösophagus. Dysphagie als klinisches Leitsymptom tritt erst spät im Verlauf der Erkrankung auf. Die Endosonographie ist die derzeit genaueste diagnostische Methode zur Bestimmung der Tumorgröße. Eine Differenzierung zwischen benignem Leiomyom und malignem Leiomyosarkom ist nur histopathologisch möglich und kann in Einzelfällen schwierig sein. Von prognostischer Bedeutung ist die Differenzierung in „low-” und „high-grade” Sarkome aufgrund der Mitosenrate. Die Differentialdiagnose umfaßt das Spindelzellkarzinom und das Karzinosarkom der Speiseröhre. Die operative Entfernung des Tumors stellt die Therapie der Wahl dar; die Fünf-Jahres-Überlebensrate liegt zwischen 30 und 40% und ist von der Tumordifferenzierung und der Tumorgröße abhängig.SummaryLeiomyosarcomas of the esophagus are rare tumors of mesenchymal origin. Apropos of a case we present clinicopathological features, diagnostic procedures and management of this seldom tumor of the esophagus. Primary gastrointestinal sarcomas cause less than 0,5% of all esophageal malign tumors, and present in ca. 5% as esophageal leiomyosarcomas. The most frequent incidence ranges between the fourth and fifth decade of life. The tumors originate from the muscular layers of the esophageal wall and are localized predominantly in the middle and distal third of the esophagus. Dysphagia is the most important and leading symptome although it presents late in the course of the illness. Endosonography is at the time the most accurate method to establish the tumor size. Differentiation between leiomyoma and leio-myosarcoma is only possible by histopathological examination and may be difficult in certain cases. Histopathological grading of the tumors as low- and high-grade sarcomas in dependence of the number of mitosis affects predominantly the prognosis of these patients. Differential diagnosis includes spindle cell carcinoma and carcinosarcoma of the esophagus. The most effective therapy consists in the complete operative removal of the tumor, in these cases five years survival rates of 30 to 40% are achieved, strongly influenced by tumor differentiation and size.Leiomyosarcomas of the esophagus are rare tumors of mesenchymal origin. Apropos of a case we present clinicopathological features, diagnostic procedures and management of this seldom tumor of the esophagus. Primary gastrointestinal sarcomas cause less than 0.5% of all esophageal malign tumors, and present in ca. 5% as esophageal leiomyosarcomas. The most frequent incidence ranges between the fourth and fifth decade of life. The tumors originate from the muscular layers of the esophageal wall and are localized predominantly in the middle and distal third of the esophagus. Dysphagia is the most important and leading symptom although it presents late in the course of the illness. Endosonography is at the time the most accurate method to establish the tumor size. Differentiation between leiomyoma and leiomyosarcoma is only possible by histopathological examination and may be difficult in certain cases. Histopathological grading of the tumors as low- and high-grade sarcomas in dependence of the number of mitosis affects predominantly the prognosis of these patients. Differential diagnosis includes spindle cell carcinoma and carcinosarcoma of the esophagus. The most effective therapy consists in the complete operative removal of the tumor, in these cases five years survival rates of 30 to 40% are achieved, strongly influenced by tumor differentiation and size.