Paul Hermanek

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.

Early (microinvasive) colorectal carcinoma. Pathology, diagnosis, surgical treatment.

The term early colorectal carcinoma is used for an infiltrating carcinoma with submucosal spread, but no involvement of the muscle coat (muscularis propria). Our experience with 249 such tumours is reported. Lymph node metastases were detected in only 3% of 130 patients subjected to classical surgery. Early colorectal carcinoma represents a cancer stage with an excellent prognosis (agecorrected 10-year survival rate 100%). The survival rates after limited therapeutic procedures (endoscopic polypectomy, local surgical excision, segmental/tubular resection) or after classical radical surgery do not differ significantly provided that certain selection criteria are strictly observed.

Local excision of cancer of the rectum.

Local excision of rectal cancer can be a part of treatment of this tumor. The authors do not feel that this procedure is only palliative. Clinical staging I and II, tumor diameter less than 3 cm, malignancy grade 1 or 2, invasion no deeper than the submucosa, and no signet-cell carcinoma are all requisites for limited, local excision of rectal carcinoma. Patients operated upon under these criteria have a five-year survival rate of 89.6±21.7 per cent for those with invasion into the submucosa and 78±49.9 per cent for those with invasion into the muscularis propria. But to get such good results, strict self control must be exercised in selecting patients.

Classification of regional lymph node metastasis from gastric carcinoma

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).

Intraoperative spillage of tumor cells in surgery for rectal cancer

Inadvertent perforation or incision into rectal carcinoma during surgery may lead to massive dissemination of tumor cells in the operative area. It was observed in 8.7 percent of 1360 radical resections for cure. In time, the incidence could be reduced from 11.0 to 5.2 percent. Intraoperative spillage of tumor cells influences the incidence of local recurrence. In the last period (1982 to 1985) in cases of spillage of tumor cells, local recurrence was seen in 39 percent as opposed to 12.9 percent in perforation or incision of the tumor. Intraoperative tumor-cell spillage has a negative effect on survival rates, reducing the relative five-year survival rate after resection for cure from 70 to 44 percent. It should be recorded in the surgical and pathologic reports and considered in the analysis of treatment results and in selection of patients for adjuvant radiotherapy.

Impact of surgeon's technique on outcome after treatment of rectal carcinoma

PURPOSE: The aim of this study was to analyze the impact of institutions and individual surgeons on long-term prognosis after curative resection of rectal carcinoma. METHODS: We used univariate and multivariate analysis of data from a German prospective, multicenter, patient-care evaluation study. RESULTS: The locoregional recurrence rates and the observed and cancer-related survival rates showed a considerable interinstitutional and intersurgeon variability. Multivariate analysis confirmed the institution and the individual surgeon as significant independent factors influencing locoregional recurrence and survival. There was a statistically highly significant correlation between the rate of locoregional recurrence and survival rate. CONCLUSIONS: The surgeons technique and skill has to focus on prevention of locoregional recurrence to achieve good long-term outcome after curative resection for rectal carcinoma. New clinical trials on adjuvant treatment have to include quality assurance for surgery and pathology and documentation of the surgeon (as local code).

A uniform residual tumor (R) classification: integration of the R classification and the circumferential margin status.

Since the introduction of the TNM residual tumor (R) classification, the involvement of resection margins has been defined either as a microscopic (R1) or a macroscopic (R2) demonstration of tumor directly at the resection margin (“tumor transected”).

Prognostic grouping : the next step in tumor classification

SummaryAt present, staging of malignant tumors is based on the anatomical extent of disease defined by the T(umor) N(odes) M(etastasis) classification. The main objective of further efforts in classifying tumors is to identify additional independent prognostic factors and to create mathematical models that may predict disease progression by prognostic grouping. This article summarizes problems, methods and the design of coordinated studies on prognostic grouping.

Pathology and biology of pancreatic ductal adenocarcinoma

Introduction: Ductal adenocarcinoma of the pancreas is a highly aggressive tumor with early local spread beyond the pancreas, predominantly to the retroperitoneum, but also with invasion of adjacent great vessels and adjacent organs. Discussion: Anterior extension may lead to perforation of the visceral peritoneum and spread within the peritoneal cavity. Cytology in peritoneal lavage can be positive before any peritoneal metastasis is seen. Invasion of lymphatics and veins as well as perineural invasion are common. The lymph drainage of the pancreas is multidirectional to superior, inferior, anterior, posterior and left lymph nodes. In node-negative cases, isolated tumor cells in the sinus of regional lymph nodes may be found by immunocytochemistry; such findings must be distinguished from micrometastasis. The same applies to isolated tumor cells in bone marrow. Prognosis: The independent prognostic significance of isolated tumor cells in the regional lymph nodes and in the bone marrow remains to be proven. For classification of anatomic extent the new, fifth edition (1997) of the UICC TNM classification should be used. The complex Japanese classification cannot be directly compared with the UICC system. Conclusion: Tumor size and histologic grade influence the extent of spread. Anatomic extent and histologic grade are the strongest predictors of outcome.

Magnetic resonance imaging (MRI)-based indication for neoadjuvant treatment of rectal carcinoma and the surrogate endpoint CRM status

AimIs it possible to reduce the frequency of neoadjuvant therapy for rectal carcinoma and nevertheless achieve a rate of more than 90% circumferential resection margin (CRM)-negative resection specimens by a novel concept of magnetic resonance imaging (MRI)-based therapy planning?Materials and methodsOne hundred eighty-one patients from Berlin and Mainz, Germany, with primary rectal carcinoma, without distant metastasis, underwent radical surgery with curative intention. Surgical procedures applied were anterior resection with total mesorectal excision (TME) or partial mesorectal excision (PME; PME for tumours of the upper rectum) or abdominoperineal excision with TME.ResultsWith MRI selection of the highest-risk cases, neoadjuvant therapy was given to only 62 of 181 (34.3%). The rate of CRM-negative resection specimens on histology was 170 of 181 (93.9%) for all patients, and in Berlin, only 1 of 93 (1%) specimens was CRM-positive. Patients selected for primary surgery had CRM-negative specimens on histology in 114 of 119 (95.8%). Those selected for neoadjuvant therapy had a lower rate of clear margin: 56 of 62 (90%).ConclusionBy applying a MRI-based indication, the frequency of neoadjuvant treatment with its acute and late adverse effects can be reduced to 30–35% without reduction of pathologically CRM-negative resection specimens and, thus, without the danger of worsening the oncological long-term results. This concept should be confirmed in prospective multicentre observation studies with quality assurance of MRI, surgery and pathology.