Primary gastrointestinal non-Hodgkin's lymphoma: I. Anatomic and histologic distribution, clinical features, and survival data of 371 patients registered in the German Multicenter Study GIT NHL 01/92.

PURPOSE: The study was initiated to obtain epidemiologic data and information on anatomic and histologic distribution, clinical features, and treatment results in patients with primary gastrointestinal non-Hodgkin's lymphomas (PGI NHL). PATIENTS AND METHODS: Between October 1992 and November 1996, 371 PGI NHL patients were eligible to evaluate clinical features. Radiotherapy and chemotherapy were stratified according to histologic grading, stage, and whether surgery had been carried out or not. RESULTS: A total of 74.8% patients had gastric NHL (PGL). Within the intestine, the small bowel and the ileocecal region were involved in 8.6% and 7.0% of the cases, respectively. Multiple GI involvement (MGI) was 6.5%. Approximately 90% of the GI NHL were in stages IE/IIE. Aggressive NHL accounted for the majority, with a distinguishable pattern in several sites. Forty percent of PGL were of low-grade mucosa-associated lymphatic tissue type. One third of large-cell lymphomas had low-grade components. Most intestinal NHL were germinal-center lymphomas. The site of origin was prognostic. In gastric and ileocecal lymphoma, event-free (EFS) and overall survival (OS) were significantly higher as compared with the small intestine or MGI (median time of observation, 51 months). In PGL, localized disease was prognostic for EFS and OS. Histologic grade influenced only EFS significantly. Numbers in intestinal lymphomas were too small for subanalyses. CONCLUSION: PGI NHL are heterogeneous diseases. The number of localized PGL allowed for detailed analyses. Larger studies are needed for stages III and IV and for intestinal NHL. A uniform reporting system for PGI NHL, in terms of definitions and histologic and staging classifications, is needed to facilitate comparison of treatment results.

Primary gastrointestinal non-Hodgkin's lymphoma: II. Combined surgical and conservative or conservative management only in localized gastric lymphoma--results of the prospective German Multicenter Study GIT NHL 01/92.

PURPOSE: The aim of the study was to obtain data on anatomic and histologic distribution, clinical features, and treatment results of patients with primary gastrointestinal non-Hodgkin's lymphomas, particularly combined surgical and conservative treatment (CSCT) versus conservative treatment (CT) alone for primary gastric lymphoma (PGL) in localized stages. PATIENTS AND METHODS: Whether the treatment included surgery was left to the discretion of each participating center. Radiotherapy (Rx) and chemotherapy were stratified according to histologic grading, stage, and the inclusion or omission of surgery as follows: patients with low-grade PGL were treated with extended-field (EF) Rx (30 Gy). In case of residual tumor after surgery or in case of CT only (in stage IIE after six cycles of cyclophosphamide, vincristine, and prednisone), an additional boost of 10 Gy was given. All patients with high-grade PGL were treated with four (stage IE) or six (stage IIE) cycles of cyclophosphamide, doxorubicin, vincristine, and prednisone followed by EF Rx (stage IE) or involved-field (IF) Rx (stage IIE). Rx dosage corresponded to low-grade NHL. RESULTS: Between October 1992 and November 1996, 106 patients had CT only. The survival rate (SR) after 5 years was 84.4% and was influenced neither by patients' characteristics nor by stage or histologic grade. Seventy-nine patients had CSCT. Their SR was 82.0%. Complete resection of the tumor (R0) was prognostic for the overall survival (P =.0165) as compared with incomplete resection. CONCLUSION: Although the study was not randomized, a stomach-conserving approach may be favored.

Operative and conservative management of primary gastric lymphoma: interim results of a German multicenter study.

PURPOSE/OBJECTIVE: Biology and appropriate management of gastrointestinal (GI lymphomas are matters of an ongoing controversial debate. To evaluate histological features, sites of involvement and management of primary GI-lymphomas, a prospective multicentric study was initiated in 10/1992. Aim of study was the further standardization of operative and conservative treatment modalities. MATERIALS AND METHODS: Study started 10/1992 and was closed 11/1996. A total of 381 evaluable patients had been accrued then. Standardized diagnostic workup included endoscopic and radiological evaluation of the complete GI-tract as well as a central histological review. Diagnosis was established after Lewin, stage classification was made after Musshoff, and histological classification was made after Isaacson. Treatment decision concerning operative or conservative management was due to the initially acting physician. Patients with resection of low grade lymphoma received total abdominal irradiation 30 Gy + 10 Gy boost to incompletely resected areas. After resection of high grade lymphoma CHOP chemotherapy (4 cycles for stage IE, 6 cycles for higher stages) after McKelvy was followed by total abdominal irradiation 30 Gy for stage IE respectively involved field irradiation 30 Gy for higher stages with 10 Gy boost to incompletely resected areas. Primary conservative- treatment consisted of six cycles COP chemotherapy after Bagley for low grade lymphomas stage > IE and total abdominal irradiation 30 Gy + 10 Gy boost to involved areas for all stages. Patients with high grade lymphomas received 4 x CHOP followed by total abdominal irradiation 30 Gy + 10 Gy boost to involved areas or 6 x CHOP plus involved field radiation therapy with 40 Gy. 257 patients are considered for analysis due to exclusion criteria of the study, 190 of them were suffered from gastric lymphoma. Their median observation time is 29 months, maximum observation time is 68 months. RESULTS: Sites of involvement were stomach in 73.4%, small bowel 9.6%, ileocoecal region 6.9%, and other sites 3.2% More than one GI site was involved in 6.9%. Gastric lymphomas achieved a survival probability of 89% after 3 years. Though surgical and conservative treatment was not randomized, outcome was analyzed in gastric NHL stages I and II (histologic subtype not considered showing no significant influence). At 3 and 5 years survival is 88% in resected cases vs. 94% and 86% in conservatively treated patients (p = 0.350). Analyzing only stages I + II(1) surgery also seems of no advantage even considering only RO-resections. There was one acute gastrointestinal bleeding under primary chemotherapy for a high grade lymphoma. Toxicities of grade III and IV WHO were rarely seen during treatment. All other acute toxicities were not more than grade II WHO. CONCLUSION: Conservative treatment in this setting is feasible. The operative approach seems not to be advantageous compared to conservative treatment and should be critically reconsidered.

Primary lymphoma of the stomach: three-year results of a prospective multicenter study. The German Multicenter Study Group on GI-NHL.

BACKGROUND: In October 1992, an ongoing prospective study on primary gastrointestinal (GI) lymphoma was initiated to evaluate histological features, sites of involvement, and management. PATIENTS AND METHODS: Until May 1996, 352 patients were enrolled, with 279 being evaluable for clinical features (208 patients presented with primary gastric lymphoma). Standardized diagnostic workup included central histologic review and endoscopic and radiologic evaluation of the complete GI tract. Primary surgery or conservative management depended on the physician's decision, followed by radiotherapy with or without chemotherapy. Treatment outcome is evaluable in 122 patients with gastric lymphoma. RESULTS: In 279 evaluable patients, the distribution of NHL was as follows: stomach 74.6%, small bowel 8.6%, ileocoecal region 6.5%, multilocal GI involvement 6.8%. In gastric lymphoma, low-grade NHLs accounted for 39%. Of the remaining high-grade NHLs, 36.1% showed simultaneous low-grade components, thus being also of MALT origin. Of 208 patients with gastric NHL, 71.1% were classified as stage I and II1. CCR rate in stomach lymphoma is significantly higher compared to those of the small bowel, whereas involvement of multiple GI organs has the worst prognosis. So far only 7 patients with gastric NHL in stages I and II presented with progressive disease or relapse. Over all stages there seems to be no difference in therapeutic outcome in surgically or conservatively treated patients. Even after R0-resection in limited stages patients appear to have no better outcome. CONCLUSION: The value of surgery in treatment of primary gastric lymphoma--as favored by most authors--should be reexamined.

[Surgical procedure in non-Hodgkin's lymphomas of the digestive system--a status quo analysis]. / Das chirurgische Vorgehen bei Non-Hodgkin-Lymphomen des Verdauungstraktes--Eine "Ist-Analyse".

A total of 329 patients were registered in the Münster multicenter study, "Gastrointestinal Lymphomas", including 118 different centers since October 1992. Primary surgical intervention was performed in 135 cases. In contradiction to the prospective results of other oncological centers, the preoperative diagnosis of non-Hodgkin lymphoma was only known in 44.4% of cases. R0 resection was achieved in only 62 of the 135 patients (46%). This study reveals the realistic situation of operative treatment of non-Hodgkin lymphomas in everyday practice.

[Microsurgery in prospective comparison with conventional transanal excision or anterior rectum resection in adenomas and superficial carcinomas]. / Mikrochirurgie (TEM) im prospektiven Vergleich zu konventioneller transanaler Abtragung oder anteriorer Rektumresektion bei Adenomen und oberflächlichen Karzinomen.

In a prospective randomized study, transanal microsurgery (TEM) was compared with anterior resection (AR) for T1-carcinomas (n = 25 vs. 28) and with local submucosal excision for adenomas (n = 90 vs. 98). The TEM procedure was superior to AR in blood loss, operation time, analgetic demand, hospitalisation in carcinoma resection and for local relapse in adenoma resection (6% vs. 22%). The 5-year survival probability between TEM and AR was 96% for both techniques, thus advocating TEM as a considerable procedure for cure of T1-rectal carcinomas.

Adenocarcinoma of the cardia in a young man: detection of somatic p53 mutation by immunohistochemistry and automated direct sequencing.

We describe the unusual case of early-onset adenocarcinoma of the cardia in a 22-year-old male. The patient died within less than one year after diagnosis was established. By immunohistochemistry, p53 expression was observed in the tumor cells. Automated direct sequencing of polymerase chain reaction (PCR) amplified DNA revealed a homozygous transition in p53 codon 280 (AGA to GGA) as the molecular basis of p53 accumulation. Previous studies suggest that gastric carcinomas with mutations in the p53 tumor-suppressor gene are associated with particularly poor prognosis when compared with tumors without p53 mutations. Since carriers of p53 mutations in the germline have a 50 percent likelihood of developing cancer before the age of 30, we examined tumor-free tissue for the presence of a germline mutation in codon 280, but none was found.

[DNA ploidy and prognosis of cardia and stomach carcinomas. A comparative flow and image cytometric analysis pf paraffin-embedded tumor sections]. / DNA-Ploidie und Prognose der Kardia- und Magenkarzinome. Eine vergleichende fluss- und bildzytometrische Untersuchung an paraffin-eingebetteten Tumorresektaten.

The prognostic relevance of DNA stem line ploidy was ascertained by comparative DNA analysis performed by flow cytometry (FCM) and by Feulgen image cytometry (ICM) of histologic slides on paraffin-embedded resection material from 221 carcinomas of the cardia and stomach. While flow cytometric detection of DNA stem line aneuploidy was rather insecure in smaller or diffuse carcinomas, the methodological restrictions of ICM were seen in a reduced measuring accuracy varying from one case to the other. This resulted in a lower security in distinguishing mere peridiploidy from real hyperdiploid DNA aneuploidy. Despite the difference of methodology, the results were principally concurring. The assessment of DNA stem line ploidy offered no appreciable information about the prognosis of Lauren's diffuse carcinomas. For intestinal carcinomas, however, there was a significant positive correlation between DNA stem line aneuploidy and the evidence of regional nodal metastases, which might explain to a considerable extent the significantly unfavorable clinical course of tumor cases with recorded DNA aneuploidy. The correlation between DNA stem line ploidy, nodal status, and clinical outcome was distinctly less strong in intestinal carcinomas of the cardia than in those of the stomach, because nodal metastatic spread of cardia carcinomas is strongly influenced by local conditions of lymph drainage and the special mechanical strain.

Clinical and functional results of abdominal rectopexy with absorbable mesh-graft for treatment of complete rectal prolapse.

OBJECTIVE: To report the long term results of abdominal rectopexy in patients with complete rectal prolapse. DESIGN: Ongoing prospective randomised study. SETTING: Department of Surgery, Westfälische Wilhelms-University, Münster. SUBJECTS: 47 patients with complete rectal prolapse operated on between 1982 and 1989. INTERVENTIONS: Abdominal rectopexy with absorbable mesh made of either polyglycolic acid (n = 17) or polyglactine 910 (n = 30). MAIN OUTCOME MEASURES: Postoperative complications and late results at a mean of 50.5 (range 2-102) months after operation. RESULTS: Thirteen patients (28%) developed postoperative complications, most of them minor; there was one enterocutaneous fistula. Thirty five patients (74%) were available for late follow up. There were no case of recurrent prolapse and 5 (14%) had developed mucosal prolapse. Of the 22 patients who had been incontinent before operation, 8 had become totally continent and 6 partially continent Overall continence improved in 18 (51%) of the 35 patients. Three patients who were continent before operation had become incontinent. CONCLUSION: Absorbable mesh is a suitable material for abdominal rectopexy.

[Therapeutic problems of cancers of the gallbladder]. / Problèmes thérapeutiques posés par les cancers de la vésicule biliaire.

Data of 32 patients who were operated for gallbladder carcinoma were evaluated in a retrospective meta-analysis. Results were compared with endoscopic retrograde cholangio-drainage (ERCP) using large size 12/14-French gauge endo-prostheses with side flaps to prevent migration. According to the TNM classification 84% of patients were classified as stage IV, 12.5% were in a stage III and 3% were in a stage II. Only 22% of cases were operated for cure (cholecystectomies, lymphadenectomy, wedge resection of the liver). All patients died in between one year on cancer, average survival was 158 days in TNM stage II, 183 days in stage III and 75 days in stage IV. Early complication rate was in stage III and 75 days in stage IV. Early complication rate was at 28% due to cardiac and pulmonary complications. No one died as a result of the operation. Endoscopic bile duct drainage (ERCP) for gallbladder carcinoma (n = 21) was shown to be superior to surgical results with an average survival of 160 days. Early complication rate (30 day interval) was at 5.6% (n = 1014), mostly due to tube occlusion with cholangitis; clinical mortality was 2.6% only (n = 393). Occlusion of the endoscopic 12/14-French gauge tube was seen after 213 days in average. Endoscopic therapy was shown to represent an independent way in gallbladder cancer treatment not only for patients defined as not suitable for operation. All own results were compared to the literature, therapeutic regimen in gallbladder carcinoma is summarized as an organigramm.

[More successful and cost effective--the non-transendoscopic method of TPCD]. / Erfolgreicher und kostensparender--die nicht-transendoskopische Methode der TPCD.

With TPCD best results are gained with large diameter endoprostheses. In this instance special duodenoscopes with a working channel of 3.2 or 4.2 mm are needed for the implantation of 10 or 12 French endoprostheses. Alternatively, using the non-transendoscopic technique large diameter endoprostheses of 14 or more French can be implanted independently from the diameter of the working channel with conventional endoscopes. We have used this method developed at our institution in 1204 patients since 1982 and compared its results with 192 patients in whom the transendoscopic technique with 7-10 French endoprostheses was administered. The success-rate (non-transendoscopic technique 94 vs transendoscopic technique 79%), early complications (5 vs 11%), method-specific mortality (0.3 vs 1%), in-hospital mortality (3.6 vs 21%) and late complications (19 vs 33%) are clearly in favour of the non-transendoscopic approach. The higher rate of early complications and consecutively higher in-hospital mortality of the transendoscopic method with 7-10 French endoprostheses was mainly due to frequent episodes of early cholangitis due to insufficient biliary drainage. The higher success-rate of the non-transendoscopic approach is method specific ("Prothesenleger" guidable). A change of the endoscope is not necessary in contradiction to the transendoscopic method. Additional costs of special duodenoscopes that can be used neither for ERCP nor sphincterotomy are superfluous.(ABSTRACT TRUNCATED AT 250 WORDS)

[Clinical and functional results of abdominal rectopexy using different fixation principles]. / Klinische und funktionelle Ergebnisse der abdominalen Rektopexie unter Verwendung verschiedener Fixierungsgrundlagen.

We report our results with abdominal rectopexy (modified Ripstein procedure, Ripstein/Corman) without resection of the colon in 63 patients using lyophylized dura-strips, Vicryl gauze or Dexon gauze, as the underlying fixation material for the mobilized rectum, presacral fascia and fixation suture material. Forty-five of 64 patients (71.4%) were reevaluated by proctoscopic examination and questioning; the mean follow-up time was 52.5 months (range 3-136 months). Postoperative mortality due to the method was 0%; the mortality was 1.6% (n = 1/63) in general for the first postoperative 30-day period as a result of cardiac complications. There were three complications (4.7%) the durating operation. Postoperative morbidity was 25.4% (16/63); infectious complications occurred in 12.7% (8/63) of cases, with one case of spontaneous closure of a pelvicutaneous fistula after intraoperative injury to the rectal wall. Full-thickness rectal prolapse appeared after rectopexy in 4.4% (2/45) (dura material alone) and mucosal prolapse was seen in 15.5% (7/45) of the follow-up group. Constipation was reduced by 28.6% (18/63) to 22.2% during the follow-up. Seventeen of 28 patients (60.7%) with incontinence showed an improvement; total continence was registered in 35.7% (10/28). The increase in continence as a result of abdominal rectopexy was significant (Wilcoxon, P = 0.05). The special aspects of being in an older age group, having a long history of procidentia, the number of deliveries, the length of the preoperative incontinence period all showed no influence on the postoperative degree of continence (Spearman's rank correlation). In 7/15 cases with persisting incontinence after rectopexy, postanal repair (Parks) was efficient in 7/7 cases leading to total or partial continence.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison between high-field-strength MR imaging and CT for screening of hepatic metastases: a receiver operating characteristic analysis.

The diagnostic performance of high-field-strength magnetic resonance (MR) imaging (1.5 T) for detection of liver metastases was compared with that of computed tomography (CT). All patients (n = 52) underwent preoperative screening for metastases by means of MR imaging with T1-weighted, proton-density-weighted, and T2-weighted pulse sequences and CT scanning with unenhanced, incremental dynamic bolus-enhanced, and delayed contrast medium-enhanced techniques. Diagnostic performance was evaluated by means of receiver operating characteristic analysis in which 800 images (400 with and 400 without lesions) and five readers (4,000 observations) were used; images were obtained from patients (n = 39) in whom the same anatomic levels were available for all MR imaging and CT studies. Direct comparison between the best MR imaging technique (T2-weighted spin-echo imaging [repetition time, 2,000 msec; echo time, 70 msec]) and the best CT technique (incremental dynamic bolus CT) showed a strong trend of superiority of T2-weighted MR imaging over incremental dynamic bolus CT. No highly statistically significant difference (P greater than or equal to .01), however, was found between these two techniques.

Detection of hepatic masses in patients with carcinoma: comparative sensitivities of sonography, CT, and MR imaging.

To evaluate the sensitivity of sonography, CT, and MR imaging in the detection of hepatic masses in carcinoma patients, we conducted a prospective study of 75 consecutive patients with gastrointestinal tumors who were admitted for surgical resection of the primary tumor. Sonography was performed with convex transducers of 3.5 and 5.0 MHz. Three noninvasive CT techniques were used: unenhanced CT scans, the incremental bolus dynamic scanning technique, and delayed scanning 4-6 hr after bolus injection of 60 g of iodine. MR images (1.5 T) were acquired as presaturated T1- and T2-weighted spin-echo sequences and as breath-holding fast low-angle shot (FLASH) 60 degrees and FLASH 15 degrees sequences. As it is difficult to distinguish benign from malignant masses solely on the basis of morphologic criteria, the techniques for each imaging method were designed to detect and not to characterize hepatic lesions. Each examination was interpreted blindly, and the results were compared with surgical findings, intraoperative sonography, and biopsy of the liver as the gold standard. All focal hepatic masses verified at surgery, malignant or benign, were included in the analysis. Sixty-five (68%) of 95 focal hepatic masses were detected by CT, 60 lesions (63%) by MR, and 50 lesions (53%) by sonography. Although lesions 1-2 cm were shown almost equally well by CT and MR (74% and 77%, respectively), the detection rate of smaller lesions (less than 1.0 cm) decreased more drastically with MR (31%) than with CT (49%). Sonography had a sensitivity of only 20% with the smaller lesions. All imaging techniques had a sensitivity of 100% for focal hepatic masses larger than 2.0 cm. Our results show that CT has a higher overall sensitivity (68%) than MR and sonography for the detection of focal hepatic masses. When the results of the three procedures are combined, the overall sensitivity is 77%. This is unsatisfactorily low, as CT and MR have a size threshold of about 1.0 cm and are relatively unreliable for the detection of smaller lesions.

Rupture of the spleen caused by primary angiosarcoma. Case report.

Splenic angiosarcoma is rare with only about 60 reported cases. A case is presented in which the tumor caused spontaneous rupture of the spleen and showed characteristics of an infiltrating echinococcosis of the liver and spleen in ultrasound and computed tomography imaging. The literature is reviewed in regard to clinical features, diagnosis and management.

[The historical development of resection surgery in pancreatic carcinoma]. / Die geschichtliche Entwicklung der resezierenden Chirurgie beim Pankreaskarzinom.

Based on the pitfalls of the past the development of pancreatic resection therapy is outlined, starting with the first distal pancreatic resection in 1882 performed by Trendelenburg. Giving details of operations from the first decades of this century the Whipple operation is described as the early cornerstone in the history of radical therapy of pancreatic cancer. Summarizing the disappointments of the seventies gives the clue to the present situation with a modified Whipple operation as the standard curative approach to pancreatic carcinoma today. Additionally, various aspects of palliative therapy for pancreatic carcinoma are discussed.