R0 resection following chemo (radio)therapy improves survival of primary inoperable pancreatic cancer patients. Interim results of the German randomized CONKO-007± trial.

PURPOSE: Chemotherapy with or without radiotherapy is the standard in patients with initially nonmetastatic unresectable pancreatic cancer. Additional surgery is in discussion. The CONKO-007 multicenter randomized trial examines the value of radiotherapy. Our interim analysis showed a significant effect of surgery, which may be relevant to clinical practice. METHODS: One hundred eighty patients received induction chemotherapy (gemcitabine or FOLFIRINOX). Patients without tumor progression were randomized to either chemotherapy alone or to concurrent chemoradiotherapy. At the end of therapy, a panel of five independent pancreatic surgeons judged the resectability of the tumor. RESULTS: Following induction chemotherapy, 126/180 patients (70.0%) were randomized to further treatment. Following study treatment, 36/126 patients (28.5%) underwent surgery; (R0: 25/126 [19.8%]; R1/R2/Rx [n = 11/126; 6.1%]). Disease-free survival (DFS) and overall survival (OS) were significantly better for patients with R0 resected tumors (median DFS and OS: 16.6 months and 26.5 months, respectively) than for nonoperated patients (median DFS and OS: 11.9 months and 16.5 months, respectively; p = 0.003). In the 25 patients with R0 resected tumors before treatment, only 6/113 (5.3%) of the recommendations of the panel surgeons recommended R0 resectability, compared with 17/48 (35.4%) after treatment (p < 0.001). CONCLUSION: Tumor resectability of pancreatic cancer staged as unresectable at primary diagnosis should be reassessed after neoadjuvant treatment. The patient should undergo surgery if a resectability is reached, as this significantly improves their prognosis.

Consensus in determining the resectability of locally progressed pancreatic ductal adenocarcinoma - results of the Conko-007 multicenter trial.

BACKGROUND: One critical step in the therapy of patients with localized pancreatic cancer is the determination of local resectability. The decision between primary surgery versus upfront local or systemic cancer therapy seems especially to differ between pancreatic cancer centers. In our cohort study, we analyzed the independent judgement of resectability of five experienced high volume pancreatic surgeons in 200 consecutive patients with borderline resectable or locally advanced pancreatic cancer. METHODS: Pretherapeutic CT or MRI scans of 200 consecutive patients with borderline resectable or locally advanced pancreatic cancer were evaluated by 5 independent pancreatic surgeons. Resectability and the degree of abutment of the tumor to the venous and arterial structures adjacent to the pancreas were reported. Interrater reliability and dispersion indices were compared. RESULTS: One hundred ninety-four CT scans and 6 MRI scans were evaluated and all parameters were evaluated by all surgeons in 133 (66.5%) cases. Low agreement was observed for tumor infiltration of venous structures (κ = 0.265 and κ = 0.285) while good agreement was achieved for the abutment of the tumor to arterial structures (interrater reliability celiac trunk κ = 0.708 P < 0.001). In patients with vascular tumor contact indicating locally advanced disease, surgeons highly agreed on unresectability, but in patients with vascular tumor abutment consistent with borderline resectable disease, the judgement of resectability was less uniform (dispersion index locally advanced vs. borderline resectable p < 0.05). CONCLUSION: Excellent agreement between surgeons exists in determining the presence of arterial abutment and locally advanced pancreatic cancer. The determination of resectability in borderline resectable patients is influenced by additional subjective factors. TRIAL REGISTRATION: EudraCT:2009-014476-21 (2013-02-22) and NCT01827553 (2013-04-09).

[How should patients with completely resected gastrointestinal stromal tumours (GIST) be followed up?]. / Welche Form der Nachsorge ist bei Patienten mit R0-resezierten gastrointestinalen Stromatumoren (GIST) sinnvoll?

UNLABELLED: Gastrointestinal stromal tumours are topical because of their uncertain biological behaviour and the potential of treatment with imatinib. In the following study we have examined which pattern of follow-up is both appropriate for detecting recurrences and cost-effective. PATIENTS AND METHODS: Between July 1997 and February 2004 we treated 43 patients diagnosed with a GIST. Patients with high risk (HR), intermediate risk (IR), or overtly malignant (OM) tumours were followed-up regularly. In 2004 we screened all patients independent of their risk of malignant disease with an ultrasound scan and endoscopy followed by endosonography. Further diagnostic procedures were carried out if necessary. RESULTS: Overall, we diagnosed recurrences in five out of 33 patients at risk (two in patients with OM, one in a patient with HR, and 2 in patients with IR according to the NIH criteria). The time period between resection of the primary tumour and recurrence ranged from 4.5 to 33 months. One of the patients with a recurrence was seen before the imatinib era, the other four were treated with imatinib mesylate. CONCLUSION: In our experience, regular follow-up should be restricted to patients with OM, HR, and IR GIST. We suggest that patients are initially seen in six months intervals for two years and annually for another three years thereafter.

[Glomus tumour of the stomach. A case report]. / Glomustumor des Magens. Ein Fallbericht.

Glomus tumours are benign neoplasms that usually arise in the skin of the extremities but have infrequently been found to occur in other sites including the stomach. We report on a 71-year-old female with non-specific epigastric pain who was diagnosed as having a small, intramural gastric tumour in addition to a cholecystolithiasis. Intraoperatively, the tumour was investigated by frozen section, but the diagnosis remained inconclusive. The ultimate histological examination showed clusters of uniform epithelioid cells surrounding wide vascular spaces. This led to the diagnosis of a glomus tumour. In a review of the recent literature,we discuss the methods and limitations of preoperative diagnostic measures.