Ilka Vogel

Isolated tumor cells are frequently detectable in the peritoneal cavity of gastric and colorectal cancer patients and serve as a new prognostic marker.

OBJECTIVE To evaluate the prognostic significance of isolated tumor cells detected by a panel of various monoclonal antibodies. SUMMARY BACKGROUND DATA Previously, we showed by using immunocytology that cancer cells are frequently found in bone marrow and peritoneal cavity samples of gastrointestinal cancer patients. METHODS Findings in bone marrow and peritoneal cavity samples were compared and correlated with the 4-year survival rate of 84 gastric and 109 colorectal patients with cancer. RESULTS Although positive results in the bone marrow showed little prognostic significance, the peritoneal cavity results correlated with the 4-year survival rate (gastric cancer: p = 0.0038; colorectal cancer: p = 0.0079). Additionally, in subgroups of patients with early (gastric cancer: p = 0.02, colorectal cancer: p = 0.48) and advanced (gastric cancer: p = 0.02, colorectal cancer: p < 0.0001) tumor stages, a correlation of immunocytologic findings and the survival rate was seen. CONCLUSIONS The detection of minimal residual disease in the peritoneal cavity serves as a new prognostic marker.

The retroperitoneal resection margin and vessel involvement are important factors determining survival after pancreaticoduodenectomy for ductal adenocarcinoma of the head of the pancreas

Abstract The prognosis of ductal adenocarcinoma of the pancreas is still poor. We analysed the factors that have a major influence on the survival of patients. Surgical specimens from 51 patients with ductal adenocarcinoma of the head of the pancreas were examined for tumour size, histological type, grade and local extension. In 7 patients the retroperitoneal resection margin was involved either macroscopically or histologically. Their mean survival was 10.6 months (1–17 months), compared with 22.7 months for the 44 patients with curative R0 resection. In 10 patients large vessels (portal and/or mesenteric vein) had to be resected; they survived for only 2-11 months, with a mean of 5 months (P<0.05). Non-R0-resected patients and patients in whom tumour-invaded vessels had to be resected constitute a high-risk group with a significantly shorter mean survival of 8.8 months, compared with 24.3 months for R0 resected patients without vessel invasion (P<0.05). Lymph node metastases were seen in 35 of 51 patients. Survival analysis based on nodal status revealed a mean survival of 33 months for patients staged as N0, 21.4 for N1a patients and 14 month for N1b patients. The differences were not statistically significant, however. Our data suggest that tumour invasion of the retroperitoneal resection margin and large vessel involvement are the major factors determining survival in patients with pancreatic cancer.

The grade of pancreatic ductal carcinoma is an independent prognostic factor and is superior to the immunohistochemical assessment of proliferation

Tumour grade is one of the prognostic factors in pancreatic ductal adenocarcinoma, but its value is controversial. In this study, the predictive value and the reproducibility of the WHO grading system were reconsidered and the possibility of supplementing it with the immunohistochemically assessed proliferative activity was investigated. Seventy resected ductal adenocarcinomas of the head of the pancreas were evaluated. A total of 60 HPF fields on two to four sections per tumour were screened for glandular differentiation, mucin production, mitosis, and nuclear atypia by two observers with different degrees of experience. Each criterion was scored and the grade was calculated from the mean value of all single scores. Corresponding slides were immunohistochemically stained with the proliferation marker Ki‐S5. The percentage of positive nuclei was assessed and a proliferation index (PI) assigned (<10%=1; 10–50%=2; >50%=3). Multivariate analysis (Cox regression) identified grade and R stage as the most significant factors for predicting survival. The PI determined on the basis of Ki‐S5 staining did not prove to be an independent prognostic factor. In 30 of 70 carcinomas, it correlated with the tumour grade. Within a given tumour grade, the cases with the least favourable prognosis could be distinguished on the basis of their PI. The inter‐observer variability was considerable, with the main differences occurring in the group of G1 tumours. According to the refined WHO criteria, the histopathological grade of pancreatic ductal carcinoma is an important independent prognostic factor, but reproducibility depends on the expertise of the observer. Criteria that relate to cellular and structural differentiation seem to be more predictive than those related to proliferation. Copyright

Surgery for ductal adenocarcinoma of the pancreatic head: staging, complications, and survival after regional versus extended lymphadenectomy.

Abstract. The purpose of this study was to evaluate the influence of regional versus extended lymphadenectomy on survival after partial pancreaticoduodenectomy for pancreatic cancer. From October 1988 to December 1991 (Department of Surgery, University of Hamburg) and from January 1992 to March 1998 (Department of Surgery, University of Kiel) 72 patients with histologically proven ductal adenocarcinoma of the pancreatic head were treated. Partial pancreaticoduodenectomy with regional lymphadenectomy was performed in 26 patients. In 46 patients lymphadenectomy was expanded to include extended retroperitoneal lymphatic and connective tissue clearance. Comparing these two groups and including only patients with R0 resections (n= 58) no significant differences in long-term survival could be shown. The following parameters were shown to have a significant or nearly significant influence on long-term survival: (1) stage of the disease: The 5-year survival of patients with stage I/II pancreatic head cancer was 63%, compared to 15% in patients with stage III/IV a + b of the disease (p= 0.0087). (2) Grading: The 1-year survival of patients with well or moderately differentiated tumors was 55%, compared to 0% for patients with poorly differentiated ductal adenocarcinoma (p= 0.0022). (3) N stage: The 5-year survival of patients in N0 stage was 46.9%, compared with 15% for N1 stage patients. The difference was not quite significant (p= 0.081). (4) Portal vein involvement: The 1-year survival was 0% in patients with R0 resections and histologically proven tumor infiltration of the portal vein, compared to 63% for patients with curative resections without portal vein involvement (p= 0.0063). In conclusion our data indicate that extensive retroperitoneal tissue clearance during pancreaticoduodenectomy for ductal pancreatic cancer does not improve survival compared to regional lymphadenectomy restricted to the right side of the mesenteric artery.

Disseminated tumour cells. Their detection and significance for prognosis of gastrointestinal and pancreatic carcinomas

Abstract. Metastatic spread is a major factor in the prognosis of cancer patients. Early detection and eradication of circulating tumour cells prior to the development of metastases could help to improve the outcome of patients after tumour resection. Disseminated tumour cells have been detected in different compartments of the body using cytological and immunostaining methods and, more recently, using different molecular biological techniques. The most frequently studied body compartments are the bone marrow, peritoneal cavity, blood and lymph nodes, but other body fluids such as urine, bile, pancreatic juice and sputum have also been analysed. At all of these sites, tumour cells have been detected. However, the specificity and sensitivity of the methods and their prognostic impact are still being debated. This review discusses the accuracy of the detection methods and the prognostic value of detecting disseminated tumour cells in the bone marrow, blood and peritoneal lavage of patients with colorectal, gastric and pancreatic carcinomas.

Tumor‐associated macrophages exhibit pro‐ and anti‐inflammatory properties by which they impact on pancreatic tumorigenesis

Pancreatic ductal adenocarcinoma (PDAC) still ranking 4th in the order of fatal tumor diseases is characterized by a profound tumor stroma with high numbers of tumor‐associated macrophages (TAMs). Driven by environmental factors, monocytes differentiate into M1‐ or M2‐macrophages, the latter commonly regarded as being protumorigenic. Because a detailed analysis of TAMs in human PDAC development is still lacking, freshly isolated PDAC‐derived TAMs were analyzed for their phenotype and impact on epithelial‐mesenchymal‐transition (EMT) of benign (H6c7) and malignant (Colo357) pancreatic ductal epithelial cells. TAMs exhibited characteristics of M1‐macrophages (expression of HLA‐DR, IL‐1β, or TNF‐α) and M2‐macrophages (expression of CD163 and IL‐10). In the presence of TAMs, H6c7, and Colo357 cells showed an elongated cell shape along with an increased expression of mesenchymal markers such as vimentin and reduced expression of epithelial E‐cadherin. Similar to TAMs, in vitro generated M1‐ and M2‐macrophages both mediated EMT in H6c7 and Colo357 cells. M1‐macrophages acquired M2‐characteristics during coculture that could be prevented by GM‐CSF treatment. However, M1‐macrophages still potently induced EMT in H6c7 and Colo357 cells although lacking M2‐characteristics. Overall, these data demonstrate that TAMs exhibit anti‐ as well as proinflammatory properties that equally contribute to EMT induction in PDAC initiation and development.

Novel Bispecific Antibodies Increase γδ T-Cell Cytotoxicity against Pancreatic Cancer Cells

The ability of human γδ T cells from healthy donors to kill pancreatic ductal adenocarcinoma (PDAC) in vitro and in vivo in immunocompromised mice requires the addition of γδ T-cell-stimulating antigens. In this study, we demonstrate that γδ T cells isolated from patients with PDAC tumor infiltrates lyse pancreatic tumor cells after selective stimulation with phosphorylated antigens. We determined the absolute numbers of γδ T-cell subsets in patient whole blood and applied a real-time cell analyzer to measure their cytotoxic effector function over prolonged time periods. Because phosphorylated antigens did not optimally enhance γδ T-cell cytotoxicity, we designed bispecific antibodies that bind CD3 or Vγ9 on γδ T cells and Her2/neu (ERBB2) expressed by pancreatic tumor cells. Both antibodies enhanced γδ T-cell cytotoxicity with the Her2/Vγ9 antibody also selectively enhancing release of granzyme B and perforin. Supporting these observations, adoptive transfer of γδ T cells with the Her2/Vγ9 antibody reduced growth of pancreatic tumors grafted into SCID-Beige immunocompromised mice. Taken together, our results show how bispecific antibodies that selectively recruit γδ T cells to tumor antigens expressed by cancer cells illustrate the tractable use of endogenous γδ T cells for immunotherapy.

Clinical usefulness, safety, and plasma concentration of ropivacaine 0.5% for inguinal hernia repair in regional anesthesia.

Background and Objective The aim of this study was to evaluate the pharmacokinetics, feasibility, and clinical effects of ropivacaine in regional anesthesia (ilioinguinal-iliohypogastric blocks [IIB], genitofemoral block plus local infiltration) for inguinal hernia repair. Methods Following ethics committee approval and informed consent, 21 male adults received 60 mL ropivacaine 0.5% (without vasoconstrictor). In 11 patients, further injections of 5 to 10 mL were given while preparing the hernial sack. Plasma concentration of ropivacaine was determined in venous blood after 10, 20, 30, 45, 60, 90, 120, and 300 minutes using reversed-phase high pressure liquid chromatography (HPLC). Results Peak plasma concentrations of ropivacaine were 1.5 ± 0.6 (0.7 to 2.6) μg/mL (mean ± SD [range]). These maximum concentrations occurred after 45 (30 to 60) minutes (median [range]). No signs of central nervous or cardiovascular toxicity were observed. Twelve of 21 patients did not need any additional analgesics within 24 hours postoperatively. One patient had a femoral motor block lasting 6 hours, 5 patients reported sensory femoral block lasting 5 to 12 hours. Patients, as well as the surgeon, were very satisfied with the procedure, and all patients stated that they would like to have it performed again that way in case of an inguinal hernia on the opposite side. Conclusion A ropivacaine dose of 60 to 70 mL of 0.5% appears adequate for regional anesthesia for inguinal hernia repair regarding conditions for surgery, safety, ambulation, and postoperative pain relief.

Detection and clinical implications of minimal residual disease in gastro-intestinal cancer.

IntroductionMetastatic dissemination is an important factor for the prognosis of patients with gastro-intestinal cancer. Exact staging is crucial to determine appropriate multimodal therapeutic strategies. At present, the sensitivity of routinely performed diagnostic techniques is suboptimal for the detection of minimal residual disease (MRD) and occult metastases since the number of disseminated tumour cells (DTCs) is mostly marginal. To amend the verification of DTCs, immunohistochemical and molecular methods were applied to retrieve epithelial cell-specific proteins in non-epithelial tissue of different body compartments or fluids. Many groups have eagerly focussed on the identification of new markers and novel tests, yet specificity and sensitivity of these methods as well as robustness in the clinical setting are frequently missing.Materials and methodsThis review critically evaluates the prognostic impact of MRD in patients with pancreatic, colorectal and gastric cancer by outlining those studies showing diagnostic results of DTC detection in lymph nodes, bone marrow, venous blood and peritoneal lavage, some of which present novel strategies.ConclusionThe analysed data concerning MRD in gastro-intestinal cancers reveal that results are undesirably heterogeneous. From a critical point of view, many clinical studies missed their chance because of small cohort size; moreover, methodological standardisation is generally lacking. On the other hand, the very encouraging results achieved so far, together with the comprehensive analyses of a few research groups, foster the prediction that DTC/MRD issues will soon expand the standard TNM classification.

The carcinoembryonic antigen and its prognostic impact on immunocytologically detected intraperitoneal colorectal cancer cells

BACKGROUND Carcinoembryonic antigen (CEA) has been suggested to promote colon cancer progression. In this study we analyzed the prognostic impact of CEA expression on intraperitoneally detected single colon cancer cells. METHODS Peritoneal lavage samples of 135 colorectal cancer patients were immunocytologically analyzed, including a staining of cellular CEA; serum CEA levels were measured; and 5-year survival rates were calculated according to immunocytological findings and CEA expression. RESULTS The worst survival rate of 20% was found in patients suffering from CEA-expressing intraperitoneal tumor cells (P = 0.0006). The prognostic impact of an intraperitoneal tumor cell finding significantly increased when serum CEA levels were elevated: only 23% survived 5 years in contrast to a 85% 5-year survival rate of patients who neither had signs of dissemination nor showed elevated serum CEA values (P = 0.0010). CONCLUSIONS This study shows that the determination of CEA expression improves the prognostic impact of an intraperitoneal tumor cell finding.