Einleitung/Background

Malignant melanoma, as one of the most aggressive forms of skin cancer, tends to develop metastases, significantly deteriorating the prognosis in affected patients. Resection of pulmonary metastases from malignant melanoma show a 5-year survival rate of 33%. Resection of liver metastases in such patients is associated with a median survival of 27 months when R0 resection is feasible. This case report underscores the significance of careful treatment planning and present a revolutionary approach in a patient with malignant melanoma metastasized in two different cavities.

Methoden/Methods
A 78- year-old male patient with a metastatic malignant melanoma in the right lung, accompanied by a concurrent metastasis in segment VII of the right liver lobe. The patient's medical history revealed a previous surgically removed melanoma from the temporal cranial skin region a decade ago.
Ergebnisse/Results

The patient underwent a posterolateral thoracotomy on the right side, followed by an anatomical resection of the lung segment IV and an atypical resection in segment VII through a phrenotomy. The postoperative course remained uncomplicated, and the patient was discharged on the 10^th postoperative day.

Zusammenfassung/Conclusion

Considerations for a surgical approach enable rapid oncological meaningful surgical treatment at advanced age with a single incision, one-time anesthesia, and uncomplicated postoperative course.

Background

Metastatic disease of the thyroid gland is a very rare site, only 2-3% of all suspected malignancies of the thyroid gland are metastases of other organs. However, autopsy studies show much higher numbers of up to 24%. The primary tumor is commonly located in the kidney, breast, lung or the digestive tract. Indication for thyroid surgery usually allows exact workup during preoperative evaluation and discrepancies from the preoperative histology are not very common. However, deviations in the postoperative diagnosis sometimes would have required different treatment regimens.

Methods

Retrospective analysis of patients recorded in EUROCRINE after thyroid surgery at the certified center of the Ordensklinikum Linz, Austria, between 2018 and 2023.

Results

1480 patients were included. 6 patients showed metastasis of extrathyroidal cancer. The primary cancer locations were renal cell carcinoma (n=3), rectal cancer (n=1), liposarcoma (n=1) and MALT lymphoma (n=1). Thyroid surgery was performed safely with low complication rates (bleeding=1.1%, hypoparathyroidism=18.9(temporary) and 1.2% (permanent), RLN paralysis= 1.2% (temporary) and 0,4% (permanent).However, preferred treatment approach would have been different if the exact diagnosis would have been known beforehand in 0.4% of the unknown lesions from other organs.

Conclusion

Thyroid surgery is performed safely in specialized centers.However, it is necessary to raise awareness for this rare location of metastasis in patients that develop a thyroidal mass and especially for those that have a history of a prior malignancy, as the surgical resection of the metastasis might not be the treatment of choice in those cases with disseminated diseases.

Einleitung/Background

Ovarian cancer is the second most common gynecological cause of death. At first presentation 75% of patients show FIGO III/IV, already having abdominal metastases. In our clinic multivisceral resection is performed interdisciplinary nearly every week.

Methoden/Methods

This is a case report of a 60 year old woman, presenting with progresive peritoneal carcinomatosis in ovarian cancer FIGO IIIC. After staging (CT, endoscopy, ascites punction) diagnosis was confirmed with diagnostic laparoscopy and biopsy. Neoadjuvantive chemoimmunotherapy was started because R0 resection was not possible due to multivisceral infiltration of cancer. Debulking surgery was then planned. By laparotomy extensive multivisceral resection was performed (adhesiolysis, deperitonealisation, maior + minor omentectomy, hysterectomy, adnexectomy, rectum resection, right hemicolectomy, splenectomy, cholecystectomy, loop ileostomy).

Ergebnisse/Results

Macroscopically no tumor was left. Chemoimmunotherapy was completed and 5 months later the ileostoma was removed.

Zusammenfassung/Conclusion

Debulking surgery and multivisceral resection in ovarian cancer requires high surgical skills. Surgeons must be flexible and master the full range of visceral surgery.

Background

Early relapse represents a major challenge in pancreatic cancer care. Up to now, little is known about the recurrence distribution pattern and its impact on time until relapse and its prognostic impact following curative intended pancreatic surgery.

Methods

1456 pancreatic resections (702 (48.2%) pancreatic cancer) have been documented in the pancreatic registry of the Ordensklinikum Linz between 2001-2021. The site of recurrence distribution and its impact on prognosis has been evaluated retrospectively.

Results

Relapse following upfront surgery has been documented in 206 patients (29.3%). Site of first recurrence distribution: liver (35%), multiple sites (28.2%), local (14.1%), lung (8.7%), peritoneum (7.8%), lymph nodes (3.4%) and others (2.8%). Site of recurrence was of significant prognostic value (in months): lung (OS 45, DFS 17, SAR 18), local (OS 36, DFS 15), nodal (OS 30, DFS 16), multiple sites (OS 26, DFS 19), peritoneum (OS 22, DFS 13) and liver (OS 19, DFS 9, SAR 5).

Chemotherapy improved survival in all subgroups, especially in nodal positive patients (+11 months), lung and liver only patients, but not in patients with local recurrence.

Conclusion

Recurrence in the liver was associated with the worst, whereas lung only was associated with the best prognosis. Site of relapse was not associated with TNM stage.

Local recurrence was unaffected by neoadjuvant or adjuvant chemotherapy exposure, but neoadjuvant chemotherapy significantly reduced relapse in liver or lung.

Survival is determined by the site of first recurrence but not by the total number of organs involved during the course of the disease.

Einleitung/Background

In 1997, Rabl et al published the state of surgical treatment of stomach cancer in Austria. Aim of this study is to assess the current state, and furthermore the changes in the last 25 years.

Methoden/Methods

We created an online survey, containing 32 questions about incidence, diagnostic, surgical treatment and postoperative complications in 2022. The survey was sent via the Austrian society for surgery to all general surgery departments.

Ergebnisse/Results

We received data from 12 of the 133 departments (9%).

180 patients, diagnosed with stomach cancer, were treated at surgical departments. The median age was 70,5 years.

In all cases an esophagogastroduodenoscopy with histological diagnosis, a computed tomography and evaluation by multidisciplinary tumor board were performed. The TNM and Laurén classifications are used routinely. The WHO classification is used mostly, the cancer genome atlas hardly ever.

139 patients (77,2%) underwent surgery. 13 operations were performed per department (0 – 28). Most commonly gastrectomy, followed by subtotal gastrectomy. 24 patients (17,2%) needed extended resection (spleen, colon, etc.), 63,3% in 1997. Two stents were placed. Minimally-invasive procedures take place at 6 departments (50%), robotic-assisted surgery at 3 departments (25%).

Surgical complications occurred in 10,8% of patients, in 23,7% in 1997. Mortality rate following resective surgery was 0,5% (8,8% in 1997).

Data collection is without problem for 10 departments, 5-year survival rate is without problem for all departments.

Zusammenfassung/Conlusion

Extended resections, complications and mortality decreased. Minimally-invasive and robotic-assisted surgeries and endoscopic stent-placement were established. Data quality is limited by low response rate.

Einleitung/Background

Metastasized gastroesophageal carcinoma (mGEC) is associated with a poor overall survival (OS) of approximately 4-10 months. Circulating tumor DNA (ctDNA) is emerging as a promising prognostic biomarker for predicting OS and relapse recently. However, until now there was little knowledge on serial ctDNA detection and its impact on relapse prediction and prognosis in mGEC.

Methoden/Methods

CtDNA detection (ddPCR) was obtained serially from 37 matched tissue (NGS) patients with GEC prior to systemic treatment and every two weeks thereafter until restaging (n=173 samples). Results have been correlated with response to treatment (restaging), overall survival (OS) and progression free survival (PFS).

Ergebnisse/Results

Pretherapeutic detection rate was 77.8%. A decline of ctDNA under 58% of the pretherapeutic value after 2 weeks of systemic treatment was accompanied with a sensitivity of 66.7 and specificity of 100%. Response to treatment assessment was correct in 54.2% (pretherapeutically pos./neg.), 85.7% (dynamics at week 2) and 85.7% (dynamics at week 4) respectively. In contrast to pretherapeutic ctDNA positivity (n.s, p=0.445), ctDNA dynamics to this cutoff was significantly associated with OS (4.1 (95% CI 2.1-6.1) vs. 13.6 (95% CI 10.4-16.6) months, p<0.000) and PFS (3.2 (1.9-4.5) vs. 9.5 (95% CI 5.5-13-5), p=0.001) after two weeks of treatment.

Zusammenfassung/Conclusion

CtDNA could be used for early evaluation of response to treatment (NACT/CTX) in the future, saving 83.3% of unevaluated treatment time and chemotoxicity of patients suffering from relapse in GEC and allowing early change of treatment with anticipated prognostic impact.

Background

ctDNA has emerged as promising biomarker in gastrointestinal cancer. However, definition for detectability and cut-offs are reported very heterogeneously.

We first in man evaluated response to treatment and correlation to actual volumetric tumor burden at a unifiable cut-off for dynamic changes during chemotherapy in 3 different major GI-cancer types (n=924 samples).

Methods

Liquid biopsy samples for n=185 stage IV patients with gastroesophageal (GEC, n=37), pancreatic (PC, n=70) and colorectal cancer (CRC, n=78) have been prospectively acquired pretherapeutically and every 2 weeks during chemotherapy until restaging, analyzed using ddPCR and correlated with response to treatment and actual volumetric tumor burden.

Results

Detection rates were 88.5% (CRC), 77.8% (GEC) and 64.3% (PC). Median pretherapeutic ctDNA MAF was 11.9% (CRC), 1.5% (GEC) and 1.6% (PC).

ctDNA was significantly correlated with total tumor volume, especially with hepatic and lung lesion volume, but not with primary tumor volume in all tumor entities.

Logistic regression revealed a decline of under 58% of the pretherapeutic MAF to predict response to treatment already after 2 weeks (CRC spec. 97.8%, sens. 92.3%, GEC spec. 100%, sens. 66.7%, PC spec. 100%, sens. 91.7%).

This was accompanied with a significant impact on OS and PFS for all tumor entities.

Discussion

ctDNA represents an already clinical applicable biomarker with remarkable sensitivity and specificity in displaying actual tumor burden, prediction of prognosis and response to treatment. This biomarker is superior to current gold standard markers CEA, CA19-9 and CA72-4 and predicts response to systemic treatment >80% faster than computed tomography.

Background

ctDNA has emerged as a promising biomarker in colorectal cancer (mCRC) with strong association to prognosis that is currently evaluated for its clinical applicability in response prediction. However, little is known about its actual derivation and correlation to tumor volume and site.

Methods

Liquid biopsy samples (n=384) for n=78 stage IV mCRC patients have been acquired pretherapeutically and every 2 weeks during chemotherapy until restaging, analyzed using ddPCR (for mutational (e.g. KRAS) and methylation markers (WIF/NPY)) and correlated with response to treatment and actual volumetric tumor burden.

Results

Pretherapeutic ctDNA was detectable in 69 patients (88.5%) and median MAF was 11.9%. Mutational pattern was very heterogeneously with 28 different mutations (KRAS 66.7%, TP 17.9%, BRAF 11.5%, NRAS 2.6%).

ctDNA correctly predicted response to treatment in 95.8% and 87.5% after only 2 weeks of treatment (CEA 74.5% and 5.5%, NPY/WIF 85.1% and 64.2%).

ctDNA was associated with total tumor volume (R=0.568, p<0.000), especially with liver tumor volume (R=0.713, p<0.000). Similar results were found for methylation (R=0.543, p<0.000; R=0.733, p<0.000) and CEA (R=0.619, p<0.000; R=0.759, p<0.000).

ctDNA dynamics after 2 weeks of treatment showed strong impact on OS (8.0 (95% CI 5.6-10.4) vs. 21.0 (95% CI 16.7-25.3) months) and PFS (2.0 (95% CI 1.3-2.7) vs. 11.0 (95% CI 9.0-13.0) months, p<0.000).

Discussion

ctDNA is correlated with actual volumetric tumor burden.

ctDNA is superior to CEA and WIF/NPY in detecting response to treatment.

ctDNA is the strongest biomarker for prognosis and predicts response to treatment after only 2 weeks of systemic treatment.

Background

ctDNA derives from distant metastases and advanced locoregional disease in pancreatic cancer (PDAC). Furthermore, ctDNA can be used to predict response to treatment after only 2 weeks of systemic treatment in mPDAC. Applicability for NACT evaluation in localized PDAC was hampered by low detection rates and thus necessity of broad-spectrum analysis and potential delay of treatment up to now.

Methods

Liquid biopsy samples of n=147 patients with locPDAC were collected preoperatively, one (n=66) and 10 days (n=30) after surgery. Samples were evaluated using ddPCR in a new testing regimen and results were correlated to volumetric findings and outcome.

Results

Pretherapeutic detection rates have improved from 10% to 36.1% (19.7% (1^st day), 13.3% (10^th day)). ctDNA did not correlate with primary tumor volume (R=0.071, p=0.605), but nodal positivity (p=0.029).

Pretherapeutic ctDNA was associated with significantly worse OS (10.1 (95%CI 4-16.2) vs. 36 (95%CI 22.1-49.9) months) and DFS (6 (95%CI 2.6-9.4) vs. 23.5 (95%CI 17.9-29.1) months).

Pretherapeutic CA19-9 was not associated with OS or DFS. Neither above 500 U/ml (p=0.285, p=0.162), nor >1000U/ml (p=0.419, p=0.495).

Postoperative ctDNA detectability did not reach statistical significance but showed strong correlation to OS (low numbers, HR 3.120, p=0.083).

Discussion

Our new testing strategy significantly improves the pretherapeutic detection rate (3x) with constantly high prognostic impact. Turnaround time from sampling of liquid biopsy to results and thus clinical assessment for treatment decisions is only 3 days.

Thus, these findings pave the way for ctDNA guided treatment decisions in locPDAC (NACT vs. upfront surgery) under study conditions.

Einleitung/Background
Gastric outlet obstructions wurden bisher zum größten Teil chirurgisch im Sinne einer genähten, oder mittels Stapler angelegten, Gastroenterostomie (GE) behandelt.
In einer modernen interventionellen Endoskopieeinheit ist eine flexibel endosonographisch angelegte GE, mithilfe von lumen apposing metal stents (LAMS), bereits eine etablierte Alternative zur operativ angelegten GE.

Methoden/Methods
Es wurde eine retrospektive Datenanalyse aller PatientInnen mit Anlage einer flexibel endoskopischen endosonographisch gezielten Gastroenterostomie mit Hilfe eines lumen apposing metal stents (Hot Axios™) von 2017 bis 01/2023 durchgeführt. Diese Methode wurde von 2017 bis 2020 getestet und ein Standard entwickelt. Ab 01/2021 wurden alle Eingriffe standardisiert durchgeführt. Es wurden peri- und postinterventionelle Komplikationen sowie die postoperative Funktionalität erhoben.

Ergebnisse/Results
35 Patienten (19 Frauen/16 Männer) erhielten im Untersuchungszeitraum eine LAMS Gastroenterostomie. 32 Patienten erhielten eine funktionelle, komplikationslose Gastroenterostomie (91,4%). 1 Patient erlitt eine postinterventionelle Blutung mit anschließend angiographischem Coiling, bei 2 Patienten kam es zu einer Fehllage des Stents.
Im Zeitraum der Lernkurve vor Standardisierung beträgt die Komplikationsrate 12,5% (1 von 8). Seit Etablierung eines standardisierten Verfahrens beträgt die Komplikationsrate 7,4% (2 von 27).
Die interventionsassoziierte Mortalitätsrate beträgt 0%.
Die Gesamtmorbidität beträgt 8,6%.

Zusammenfassung/Conclusion

Die Durchführung einer endoskopischen Gastroenterostomie ist eine technisch äußerst anspruchsvolle Intervention, welche ein standardisiertes Vorgehen erfordert. Seit Etablierung eines Standards konnten die Zahlen der sicheren Durchführung gesteigert und die Interventionsdauer verkürzt werden. Die Durchführung einer LAMS Gastroenterostomie sollte nur von Untersuchern mit hoher Expertise in Endosonographie durchgeführt werden.

Introduction: Hyperthermal intraperitoneal chemotherapy (HIPEC) in combination with cytoreductive surgery (CRS) has been increasingly used to treat peritoneal metastases in colorectal cancer. The aim of this study is to evaluate the clinical effectiveness as well as the complication and mortality rates of this therapy option.

Methods: Patients with peritoneal metastatic colorectal cancer (small bowel (n=3; 3.5%), right colon (n=35; 41.2%), left colon (n=41; 48.2%) and appendix (n=6; 7.1%)) who underwent CRS/HIPEC at the Ordensklinikum Linz (OKL) between 2013 and 2022 (n=85/145) versus a matched comparison group (chemotherapy (CTX) alone for peritoneum only colorectal cancer (PERonly mCRC)) were analysed retrospectively from our prospective database.
Results: Tumours were classified as T4 in 67.1% of patients (n=57) and 58.8% (n=50) were nodal positive. The peritoneal carcinoma index (PCI) was <10 (61.9%), 11-15 (12%) and ≥16 (13.1%). Median PCI was 4 (IQR 2-11). Any complication was registered in 53% (n=45), of which 36.5% CD<3b and 16.5% CD ≥3b. However, 30d mortality was 0%.

CRS/HIPEC was superior to CTX alone in both median PFS (58 months (95% CI 23.7-92.3), p=0.022) and OS ((mean 68. 6 (95% CI 58. 4-78. 7) vs. 26. 4 months (95% CI 15. 8-36. 9); p<0.000; (median not reached in CRS/HIPEC)).

Conclusion: CRS/HIPEC shows a clear survival advantage in PERonly mCRC compared to chemotherapy alone. Therefore, the possibility of CRS/HIPEC therapy should be considered in these patients. In order to ensure a complete cytoreduction with low morbidity and mortality, this procedure should be performed in a high-volume centre.

Introduction/Background:

Pulmonary round lesions are one of the most common comorbidities in both the initial presentation and the oncological follow-up of patients with breast cancer. However, recent years' experiences underscore that the straightforward assumption of a lung metastasis is not always accurate.

Methods:

Based on three cases, various methods for diagnosing and treating pulmonary round lesions were investigated. Diagnostic procedures such as CT-guided biopsies, tumor marker monitoring, and positron emission tomography were employed to identify and characterize these tumors.

Results:

Through the meticulous investigation using the aforementioned methods, different diagnoses were established, leading to significant therapeutic consequences.

Summary/Conclusion:

Histological confirmation of a pulmonary round lesion and subsequent surgical resection should be considered standard procedures. These case studies illustrate the spectrum of possible diagnoses and the resulting diverse therapeutic approaches.