Co-Planar Stereotaxic Atlas of the Human Brain—3-Dimensional Proportional System: An Approach to Cerebral Imaging, J. Talairach, P. Tournoux. Georg Thieme Verlag, New York (1988), 122 pp., 130 figs. DM 268

There is no consensus definition of acute renal failure (ARF) in critically ill patients. More than 30 different definitions have been used in the literature, creating much confusion and making comparisons difficult. Similarly, strong debate exists on the validity and clinical relevance of animal models of ARF; on choices of fluid management and of end-points for trials of new interventions in this field; and on how information technology can be used to assist this process. Accordingly, we sought to review the available evidence, make recommendations and delineate key questions for future studies. We undertook a systematic review of the literature using Medline and PubMed searches. We determined a list of key questions and convened a 2-day consensus conference to develop summary statements via a series of alternating breakout and plenary sessions. In these sessions, we identified supporting evidence and generated recommendations and/or directions for future research. We found sufficient consensus on 47 questions to allow the development of recommendations. Importantly, we were able to develop a consensus definition for ARF. In some cases it was also possible to issue useful consensus recommendations for future investigations. We present a summary of the findings. (Full versions of the six workgroups' findings are available on the internet at http://www.ADQI.net
 ) Despite limited data, broad areas of consensus exist for the physiological and clinical principles needed to guide the development of consensus recommendations for defining ARF, selection of animal models, methods of monitoring fluid therapy, choice of physiological and clinical end-points for trials, and the possible role of information technology.

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Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group.

The transdifferentiation of epithelial cells into motile mesenchymal cells, a process known as epithelial-mesenchymal transition (EMT), is integral in development, wound healing and stem cell behaviour, and contributes pathologically to fibrosis and cancer progression. This switch in cell differentiation and behaviour is mediated by key transcription factors, including SNAIL, zinc-finger E-box-binding (ZEB) and basic helix-loop-helix transcription factors, the functions of which are finely regulated at the transcriptional, translational and post-translational levels. The reprogramming of gene expression during EMT, as well as non-transcriptional changes, are initiated and controlled by signalling pathways that respond to extracellular cues. Among these, transforming growth factor-β (TGFβ) family signalling has a predominant role; however, the convergence of signalling pathways is essential for EMT.

Molecular mechanisms of epithelial–mesenchymal transition

background Postoperative chemoradiotherapy is the recommended standard therapy for patients with locally advanced rectal cancer. In recent years, encouraging results with preoperative radiotherapy have been reported. We compared preoperative chemoradiotherapy with postoperative chemoradiotherapy for locally advanced rectal cancer. methods We randomly assigned patients with clinical stage T3 or T4 or node-positive disease to receive either preoperative or postoperative chemoradiotherapy. The preoperative treatment consisted of 5040 cGy delivered in fractions of 180 cGy per day, five days per week, and fluorouracil, given in a 120-hour continuous intravenous infusion at a dose of 1000 mg per square meter of body-surface area per day during the first and fifth weeks of radiotherapy. Surgery was performed six weeks after the completion of chemoradiotherapy. One month after surgery, four five-day cycles of fluorouracil (500 mg per square meter per day) were given. Chemoradiotherapy was identical in the postoperative-treatment group, except for the delivery of a boost of 540 cGy. The primary end point was overall survival. results Four hundred twenty-one patients were randomly assigned to receive preoperative chemoradiotherapy and 402 patients to receive postoperative chemoradiotherapy. The overall five-year survival rates were 76 percent and 74 percent, respectively (P=0.80). The five-year cumulative incidence of local relapse was 6 percent for patients assigned to preoperative chemoradiotherapy and 13 percent in the postoperative-treatment group (P=0.006). Grade 3 or 4 acute toxic effects occurred in 27 percent of the patients in the preoperative-treatment group, as compared with 40 percent of the patients in the postoperative-treatment group (P=0.001); the corresponding rates of long-term toxic effects were 14 percent and 24 percent, respectively (P=0.01). conclusions Preoperative chemoradiotherapy, as compared with postoperative chemoradiotherapy, improved local control and was associated with reduced toxicity but did not improve overall survival.

Preoperative versus Postoperative Chemoradiotherapy for Rectal Cancer

Colorectal cancer (CRC) is one of the most common malignancies in the United States. Every 3 years, the American Cancer Society provides an update of CRC incidence, survival, and mortality rates and trends. Incidence data through 2013 were provided by the Surveillance, Epidemiology, and End Results program, the National Program of Cancer Registries, and the North American Association of Central Cancer Registries. Mortality data through 2014 were provided by the National Center for Health Statistics. CRC incidence rates are highest in Alaska Natives and blacks and lowest in Asian/Pacific Islanders, and they are 30% to 40% higher in men than in women. Recent temporal patterns are generally similar by race and sex, but differ by age. Between 2000 and 2013, incidence rates in adults aged ≥50 years declined by 32%, with the drop largest for distal tumors in people aged ≥65 years (incidence rate ratio [IRR], 0.50; 95% confidence interval [95% CI], 0.48-0.52) and smallest for rectal tumors in ages 50 to 64 years (male IRR, 0.91; 95% CI, 0.85-0.96; female IRR, 1.00; 95% CI, 0.93-1.08). Overall CRC incidence in individuals ages ≥50 years declined from 2009 to 2013 in every state except Arkansas, with the decrease exceeding 5% annually in 7 states; however, rectal tumor incidence in those ages 50 to 64 years was stable in most states. Among adults aged <50 years, CRC incidence rates increased by 22% from 2000 to 2013, driven solely by tumors in the distal colon (IRR, 1.24; 95% CI, 1.13-1.35) and rectum (IRR, 1.22; 95% CI, 1.13-1.31). Similar to incidence patterns, CRC death rates decreased by 34% among individuals aged ≥50 years during 2000 through 2014, but increased by 13% in those aged <50 years. Progress against CRC can be accelerated by increasing initiation of screening at age 50 years (average risk) or earlier (eg, family history of CRC/advanced adenomas) and eliminating disparities in high-quality treatment. In addition, research is needed to elucidate causes for increasing CRC in young adults. CA Cancer J Clin 2017. © 2017 American Cancer Society. CA Cancer J Clin 2017;67:177-193. © 2017 American Cancer Society.

Colorectal cancer statistics, 2017.

Part 1. The Erlanger endo-trainer.

Introduction Outcomes in rectal cancer have improved dramatically after the introduction of total mesorectal excision (TME). Recently, the TME concept has been transformed into that of complete mesocolic excision (CME) in an attempt to improve prognosis for patients with colon cancer. Patients and methods Multidisciplinary team (MDT) workshops including the CME concept were held annually between 2004 and 2008 at the Karolinska University Hospital. The workshops focused on preoperative staging, surgery and histopathology and included lectures and live surgery sessions. To compare survival before and after the “Stockholm Colon Cancer Project” all patients diagnosed with a right sided colon cancer between January 1, 2001 and December 31, 2003 (Group 1) and from January 1, 2006 until December 31, 2008 (Group 2) in Stockholm were identified from the Swedish ColoRectal Cancer Registry (SCRCR). Results The proportion of patients having a tumour resection and the proportion having emergency surgery was higher in Group 1. There were more early tumours and more R0 resections in Group 2. Overall survival in all diagnosed patients and disease free survival after tumour resection was improved in the second time period. Discussion Surgical teaching programmes may have an impact on the management and outcome in colon cancer. The exact impact from the “Stockholm Colon Cancer Project” cannot be established, however it is likely that it contributed to the improved survival.

Improved survival after an educational project on colon cancer management in the county of Stockholm--a population based cohort study.

PURPOSE: This study contained herein assessed long-term results, toxicity, and prognostic variables following combined modality therapy of patients with International Union Against Cancer Classification T1–4, N0–3, M0 squamous-cell carcinoma of the anal canal. PATIENTS AND METHODS: Between 1985 and 1996, 62 patients completed treatment with combined modality therapy. A median total dose of 50 Gy was given to the primary, perirectal, presacral, and inguinal nodes followed by a local boost in selected cases. 5-Fluorouracil was scheduled as a continuous infusion of 1,000 mg/m2 per 24 hours on days 1 to 5 and 29 to 33 and mitomycin C as a bolus of 10 mg/m2 on days 1 and 29. Routinely processed paraffin-embedded sections were stained using monoclonal antibodies for detection of proliferating cell nuclear antigen and MIB1 (Ki-67) antigen to determine the labeling index. In addition, DNA ploidy was assessed after Feulgen staining. RESULTS: Actuarial cancer-related survival, no evidence of disease survival, and colostomy-free survival rates at five years were 81, 76, and 86 percent, respectively. In univariate analysis, T category (T1/2 vs. T3/4) was predictive for no evidence of disease survival (87vs. 59 percent;P=0.03) and colostomy-free survival (94vs. 73 percent;P=0.05). N category (N0vs. N1–3) influenced actuarial cancer-related survival (85vs. 58 percent;P=0.002) and no evidence of disease survival (80vs. 53 percent;P=0.02). A higher proliferative potential as measured by the MIB1 labeling index was associated with a better colostomy-free survival (90vs. 50 percent;P=0.04). In multivariate analysis, actuarial cancer-related survival was only influenced by the N category (P=0.03) and no evidence of disease survival by N category (P=0.03) and mitomycin C dose (P=0.04). Salvage abdominoperineal resection achieved long-term control in only four of seven patients with local failures. CONCLUSION: Treatment with a combination of radiotherapy and chemotherapy is safe and effective for patients with anal canal carcinoma. Abdominoperineal resection is indicated as a salvage procedure in nonresponding and recurrent lesions and may be of benefit in a small subgroup of patients with poor prognostic factors.

Sphincter preservation with chemoradiation in anal canal carcinoma : Abdominoperineal resection in selected cases?

Die onkologischen Probleme bei laparoskopisch colorectalen Eingriffen in kurativer Intention bestehen im Auftreten von Port-site-Metastasen, in einer inadaquaten Radikalitat, einer Tumorzellverschleppung durch ungeschutzte Praparatebergung und unzureichende Operationstechnik sowie Nichtbeachtung technisch-onkologischer Grenzen bei bestimmten Tumorlokalisationen. Die bisher vorliegenden Untersuchungen ergeben eine mehr mechanische Pathogenese der Port-site-Metastasen durch Verschleppung von Tumorzellen in die Trokareinstichstellen uber Instrumente, Trokare und Resektionspraparate. Durch entsprechende Vorsichtsmasnahmen scheint somit eine Vermeidung moglich. Das CO2-Pneumoperitoneum spielt anscheinend eine untergeordnete Rolle bei der Entstehung der Port-site-Metastasen. Die onkologische Radikalitat laparoskopischer Eingriffe beim colorectalen Carcinom kann bei fehlenden Langzeitdaten zur Zeit nicht beurteilt werden. Es liegen lediglich vereinzelte Untersuchungen zur Zahl der bei den Eingriffen mitentfernten Lymphknoten vor. Die Anzahl scheint nicht die bei vergleichbaren offenen Resektionen zu erreichen, eine genauere Analyse muste jedoch die selektionierten Indikationen nach Tumorgrose und -lokalisation berucksichtigen. Die Vielzahl der moglichen Fehler und Gefahren der onkologischen laparoskopischen Chirurgie fuhrt zu der klaren Forderung, das die Eingriffe nur innerhalb von prospektiven klinischen Studien mit selektionierten Indikationen erfolgen sollten. Eine prospektiv randomisierte Studie fur alle Tumorstadien und -lokalisationen ist vor diesem Hintergrund kritisch zu werten.

Fehler und Gefahren in der onkologischen laparoskopischen Chirurgie

Background

The aim of this study was to compare the risk scores of Fong et al., Nordlinger et al., and the TNM classification of colorectal liver metastases proposed by the UICC.



Methods

Data from 282 consecutive patients undergoing 303 liver resections for metastatic colorectal cancer between 1995 and 2006 at the Department of Surgery, University of Erlangen were analyzed. The median follow-up time was 34 months. A curative (R0) resection was performed in 92% of the patients.



Results

Applying the clinical risk score of Fong with preoperative data identified three risk groups. The survival rates between “low risk” (n = 22) and “intermediate risk” (n = 222) diverged (P = 0.073). The survival rates between “intermediate risk” and “high risk” (n = 59) differed significantly (P = 0.030). Using the risk scoring system of Nordlinger, patients were divided into two risk groups (i.e., “low risk” (n = 218) and “intermediate risk” (n = 68)). Significant differences in survival between the groups were noted (P = 0.012). Applying the clinical TNM classification of colorectal liver metastases revealed no significant differences in survival between the risk groups.



Conclusions

Our study found the clinical risk score developed by Fong et al. to be a reliable preoperative prognostic tool for selecting patients for surgical resection of colorectal liver metastases. J. Surg. Oncol. 2009;100:349–357. © 2009 Wiley-Liss, Inc.

Werner Hohenberger

Papers

Part 1. The Erlanger endo-trainer.

Improved survival after an educational project on colon cancer management in the county of Stockholm--a population based cohort study.

Sphincter preservation with chemoradiation in anal canal carcinoma : Abdominoperineal resection in selected cases?

Fehler und Gefahren in der onkologischen laparoskopischen Chirurgie

Comparison of clinical risk scores predicting prognosis after resection of colorectal liver metastases.