Abstracts 4. Gemeinsamer Jahreskongress der ... - SWISS KNIFE

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Aspirates wurde mit dem Panzytokeratin-Marker A45-B/B45 gefärbt und in einem automatischen
Bild-Analysesystem auf epitheliale Tumorzellen untersucht. Ein Pathologe verifizierte
positive Befunde visuell.
Results: Die SLN-Identifikation gelang in 82/98 Fällen (84%). Median wurden 3 SLN
(Variations-breite 1-13) gefunden. Bei 16 Patienten (20%) wurden SLN-Makrometastasen diagnostiziert.
Bei 8 Patienten (10%) konnten Mikrometastasen oder isolierte Tumorzellen in den
SLN nachgewiesen werden. In 58 Fällen (70%) wurden keine nodalen Tumorinfiltrate beobachtet.
Die KM-Analyse war positiv bei 15 SLN negativen (18%) und 6 SLN positiven Patienten
(7%); die KM-Analyse war negativ bei 43 SLN negativen (53%) und 18 SLN positiven
Patienten (22%). Es bestand keine Korrelation (p = 1,0; Fisher’s exact-Test) zwischen dem
Nachweis von KM- und SLN-Metastasen. Positive KM-Aspirate zeigten im Durchschnitt 7 epitheliale
Tumorzellen pro 50 Millionen Zellen. KM-Mikrometastasen konnten in 5/16 Patienten
(31%) mit SLN-Makrometastasen und 1/8 Patienten (12%) mit SLN-Mikrometastasen oder
isolierten Tumorzellen nachgewiesen werden (p = 0,6; Fisher’s exact-Test).
Conclusion: Der Nachweis von Mikrometastasen im Knochenmark und von Metastasen in
Sentinel-Lymphknoten korreliert bei Kolonkarzinom-Patienten nicht. Daher sind beide Befunde
als unabhängige Indikatoren einer Tumorzelldissemination des Kolonkarzinoms zu bewerten.
28.02
R. Ipaktchi 1 , B. Egger 2 , G. Beldi 3 , D. Candinas 4
1 DMLL, Klinik und Poliklinik für Viszerale und Transplantationschirurgie, 3010 Bern/CH,
2 Department of Visceral and Transplantation Surgery, Inselspital, University of Bern, 3010
Bern/CH, 3 Clinic of Visceral and Transplantation Surgery, Inselspital Bern, 3010 Bern/CH,
4 Vchk, Inselspital, Bern/CH
GIST-Patienten: Gutes Langzeitüberleben trotz hoher Rezidivrate mittels repetitiver resezierender
Chirurgie und Imatinib-Therapie
Objective: Gastrointestinale Stroma Tumore (GIST) machen 1-3 % aller gastrointestinalen
Malignome aus. Die Prognose richtet sich nach der Fletcher Klassifikation, bei welcher die
Mitoseaktivität und die Grösse der Tumore bedeutend sind. Wichtig ist auch die chirurgische
Resektion im Gesunden ohne „Spilling“. Ziel der Studie: Analyse der Behandlungsergebnisse
unseres Krankengutes mit GIST.
Methods: Zwischen 1995 und 2005 wurden bei uns 41 Patienten (23 Männer, 18 Frauen,
Durch-schnittsalter: 67 Jahre) mit GIST bei behandelt. Dabei konnten retrospektiv bei 31
Patienten die Symptome, Operation, Tumorlokalisation, Klassifikation nach Fletcher und
Rezidive erfasst werden.
Results: Symptome: GI-Blutung 27%, Schmerzen 20%, Gewichtsverlust 13%, Dysphagie 7%,
pal-pabler Tumor 6%, keine Symptome 27%. Lokalisation: Magen 52%, Dünndarm 25%, Ösophagus
13%, Kolon/Rectum 3%, retroperitoneal 7%. Ferner zeigte sich bei 23% ein synchroner
maligner Zweit-Tumor. Chirurgisches Vorgehen: laparoskopisch 10%, offen 90%.
Resektion: R0-Resektion in 71%, R1-Resektion in 13%, Enukleation in 16%. Perioperative
Mortalität: 0%. Fletcher Klassifikation: Grad I: 35%, Grad II: 29%, Grad III: 13%, und Grad IV:
22%. Nach einer medianen Beobachtungszeit von 47 (4-119) Monaten zeigten 26% der
Patienten nach durchschnittlich 32 (13-66) Monaten Rezidive: 57% bei Grad IV- (38 Mo) 25%
bei Grad III- (35 Mo.), 11% bei Grad II (13 Mo) und 18% bei Grad I-Tumoren (29 Mo). 3
Patienten sind verstorben, wobei nur einer am Tumorleiden. 6 Patienten wurden im Verlauf mit
Imatinib (4 bei Rezidiv, 2 ohne Rezidiv) behandelt und bei 6 Patienten wurden z.T. multiple
Resektion durchgeführt (-8x).
Conclusion: GIST sind maligne Tumor mit hohen Rezidvraten. Auch bei „low-risk“ -Tumoren
(Grad I n. Fletcher) findet sich immer noch ein Rezidivrate von fast 20% („high risk“: 57%).
Allerdings kann mit onkologischer Chirurgie (z.T. multipel) und dem Einsatz von Imatinib
(Glivec), unabhängig vom initialen Tumorstadium und dem Auftreten von Rezidiven, ein gutes
Langzeitüberleben erreicht werden. Mit Ausnahme eines Patienten (Grad IV mit
Peritonealkarzinose; 17 Monate Überleben) und einer anderen (Sepsis nach Narbenhernienrepair)
sind alle Patienten mit Rezidiven nach durchschnittlicher Verlaufszeit von 87 Monaten
(49 –119 Mo) am Leben.
28.03
D. Perez 1 , N. Demartines 1 , D. Jaeger 2 , P. Clavien 3
1 Dept. of Visceral and Transplant Surgery, University Hospital of Zurich, 8091 Zurich/CH, 2 Nat.
Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg/DE, 3 Swiss Hpb Center,
Dept. Visceral and Transplant Surgery, University Hospital of Zurich, 8091 Zurich/CH
Prognostic value of protein S100 expression in gastrointestinal stromal tumor
Objective: To assess the prognostic value of protein S100 expression in Gastrointestinal
Stromal Tumor (GIST) in patients undergoing a curative resection. GIST tumors display a high
variability in their malignant behaviour. The only established predictors of poor outcome are
the mitotic rate and the size of the tumor. Protein S100 expression is found predominantly in
neurogenic tissue and is an established tumor marker for melanoma. S100 expression in
GIST varies between 5% and 76%, but its prognostic value has not been described yet. We
hypothesize that S100 expression may predict outcome in patients undergoing a curative
resection.
Methods: Clinical and histopathological slides of 35 GIST patients after curative resection in
our institution between 1995 and 2004 were reviewed. The following data were analyzed for
their putative value in predicting outcome: age, gender, primary tumor site, size, mitotic rate,
positive immunostaining (S100, desmin, alpha smooth muscle actin (aSMA), CD117 and
CD34). Tumors were designated positive for immunostaining when more than 10% of the
tumor cells showed a positive reaction. Primary endpoints in this study were survival and
recurrence after complete resection.
Results: Among the 35 patients, there were 18 men and 17 women with a median age of 48
years. The median follow-up was 52.2 months (1-235 months). At the time of analysis 29
patients (82.9%) were alive and 6 (17.1%) had died from GIST. Immunostaining was positive
for S100 in 33% of the patients, for CD117 in 71%, for CD34 in 54%, for aSMA in 22% and for
Desmin in 9%. The multivariate analysis identified positive immunoreactivity for S100 to be the
sole significant marker of poor prognosis (p=0.0058). All other tested markers did not correlate
with prognosis. Consistent with previous report, tumor size was also identified as a significant
prognostic factor (p=0.034). A trend for poor prognosis was also documented in
patients with a high mitotic activity (p=0.06). Age, gender and primary tumor site failed to indicate
a poor outcome.
Conclusion: The present series suggests that the expression of S100 is an excellent novel predictor
of poor prognosis after curative resection of GIST. Taken together with the size of the
tumor and the mitotic rates, S100 may become an important additional marker to grade the
malignant potential of GIST.
28.04
O.J. Wagner 1 , C. Von der Brelie 1 , S.W. Schmid 2 , D. Candinas 3 , C.A. Seiler 4
1 Dpt. of Viszeral and Transplantation Surgery, Inselspital, University of Bern, 3010 Bern/CH,
2 Visceral and Tranplantation Surgery, University Hospital of Bern/Inselspital, 3010 Bern/CH,
3 Vchk, Inselspital, Bern/CH, 4 Visceral and Transplantation Surgery, University Hospital of Bern,
3010 Bern/CH
Lymphadenectomy (modified neck dissection) and its morbidity in well differentiated thyroid
cancer: is it justified?
Objective: Due to the natural history and the slow clinical evolution of well-differentiated thyroid
cancer (DTC) the influence of lymphadenectomy (LA) on late mortality is not yet clarified.
According to the generally accepted treatment strategies for oncologic diseases, radical
resection with (neo-) adjuvant treatment is a therapeutic standard. According to this we perform
in DTC total thyroidectomy (TR) combined with initial LA of the cervico-central and ipsilateral
cervico-lateral compartment (modified neck dissection, MND). The short term aim of this
study is to evaluate the negative effects (additional morbidity) of this extended approach and
wether this procedure is recommendable in all cases with DTC.
Methods: Between 1995 and 2005, 181 patients (140 female/ 41 male), mean age of 52±18
years with DTC (137 papillary thyroid carcinoma/ PTC, 44 follicular thyroid carcinoma/ FTC)
underwent surgery. Extent of the surgery was based on histological diagnosis provided either
by intraoperative frozen section or rapid definitive histology within max. 36 hours. All patients
with intraoperatively diagnosed malignoma underwent TR and MND (Group A, n=73).
Patients with unclear intraoperative diagnosis (n=108), but malignancy in early definite workup
(max 36h) underwent completion thyreoidectomy (if not primarily performed, n=38) with
(Group B, n=51) or without MND (Group C, n=57) within 3,9±1,8 days. Excluded of this procedure
were patients with significant co-morbidity. Morbidity of all patients was collected prospectively
but evaluated retrospectively. Tumor stage: pT1, n=61; pT2, 62; pT3, 29; pT4; 29.
Results: Sensitivity of intraoperative histological diagnosis was 43,2%. Specific morbidity
included permanent recurrent laryngeal nerve palsy (A=3.9%, B=3,4%, C=1,1%) and permanent
hypocalcaemia (A= 1,4%, B=0,9%, C=1,1%) as main criterias. General complications as
lymphatic fistula and secondary hemorrhage were seen in 6,8 % of group A, 1,7% group B
and 2,1% group C. (Specific Morbidity was in all groups n.s.)
Conclusion: The „additional” morbidity of MND in combination with initial thyreoidectomy or
early completion surgery seems to be insignificant in patients. We conclude that therefore this
in other fields oncologic correct strategy should be included in primary surgery for all patients
with DTC. The influence of this „correct” oncologic surgical concept on late morbidity will be
further evaluated.
28.05
B. Roche 1 , G. Zufferey 2 , J. Robert-Yap 3
1 Chirurgie, Unité de Procotlogy HUG, 1211 Geneve 14/CH, 2 Chirurgie, Hôpital Zone de Nyon,
Nyon/CH, 3 Chirurgie, hug procotologie, 1211 Geneve 14/CH
Results of 53 surgical decompression of pudendal nerve neuralgia
Objective: Anatomy: The pudendal nerve supplies the principle innervation of the perineum.
The pathway of this nerve runs deeply through the perineum and is subjected to compression
in various zones: between the infra-spinous and the sacro-coccygeal ligaments, between
the sacro-tuberal and the sacro-spinous ligaments, and in Alcock’s canal, at the level of the
obturator internus. This compression can lead to a syndrome of perineal pain.
Methods: Symptoms: The signs and symptoms of this syndrome are typical of a classical
nerve compression syndrome. However, due to its atypical location and presentation, perineal
pain due to pudendal nerve compression, presents a diagnostic challenge. The pain of
pudendal nerve compression is often described as burning in the perineum, occurring consistently
in the same region, unilaterally, and increasing in sitting position. These symptoms
should evoke the thought of pudendal nerve compression.
Results: Diagnosis and Treatment: The diagnosis relies heavily on a good history and clinical
examination. Electrophysiological tests and diagnostic imaging are useful to exclude other
pathology. From January 2000 to February 2004 diagnostic infiltration was performed in 112
patients in our institution. The pain diminished in 97 cases. Infiltration alone was therapeutic
in 27 patients (24.1%). In 35 out of 53 patients (66.1%), symptom relief was achieved one
year after posterior transgluteal decompression surgery. 18 patients had no amelioration of
the pain. Degradation of the symptoms was not noted after treatment.
Conclusion: Conclusion: Pudendal nerve compression is not a rare condition. Diagnosis is
based on the history and physical and confirmed with infiltration. The infiltration alone can
treat the pain in 24% of the cases. Decompression surgery may be proposed when the pain
is recurs. The post operative success rate is 66.1% in our series. The effect is not immediate,
possibly taking up to one year for maximal benefit, and the patients should be informed of this
prior to the procedure. A multidisciplinary approach to the treatment of this chronic pain syndrome
is mandatory.
28.06
J.M. Heinicke 1 , D. Candinas 2 , B. Egger 2
1 Vchk, Inselspital, 3010 Bern/CH, 2 Vchk, Inselspital, Bern/CH
Distal malabsorptive Roux-en-Y gastric bypass with minimal restrictive component for the
treatment of super- and mega-obesity: pilot study results
Objective: Gastric bypass procedures are mainly based on restriction and may be combined
to different degrees of malabsorption. They are associated with specific long-term consequences
on quality of life and longterm maintenance of weight loss. We present early results
using a distal, essentially malabsorptive Roux-en-Y gastric bypass (mRYGB) with only minimal
restrictive component for patients with a BMI >50 and >60 kg/m2.
Methods: Unlike the classical Roux-en-Y gastric bypass, we avoided the implied restrictive
measures by forming a gastric pouch of at least 60 ml. The whole small intestine was measured,
a biliopancreatic limb of 100 cm and a common channel of 110 – 150 cm depending
on the actual BMI of the patient were created. The rest of the small bowel was used as alimentary
limb. 15 consecutive open and 8 consecutive laparoscopic procedures were prospectively
analysed.
swiss knife 2006; special edition 47