Accuracy of endorectal ultrasound after preoperative radiochemotherapy in locally advanced rectal cancer

Objectives: Factors limiting the accuracy of endorectal ultrasound in staging, locally advanced primary rectal cancer after preoperative neoadjuvant radiochemotherapy (RCT) were evaluated. Methods: Patients (n= 84) with initial locally advanced rectal cancer (uT3/uT4) undergoing R0 resection were investigated after preoperative treatment that combined radiotherapy up to 45 Gy with two cycles of chemotherapy (5-FU and leucovorin on d 1–5 and 22–28). At 4 to 6 weeks after completion of RCT and before tumor resection, preoperative endoluminal ultrasound was performed. Results: The accuracy to predict the depth of tumor infiltration (T-category) was found to correlate with downstaging. The T-category was correctly staged before surgery in 15 of the 51 responders (29%) and in 27 of 33 nonresponders (82%), whereas misinterpretation occurred in 36 of the responders (71%) and in 6 of the nonresponders (18%) (p < 0.001). Neither tumor distance from anal verge nor tumor location correlated with the staging accuracy. Lymph node involvement was correctly assessed in 48 patients (57%). Wall invasion was correctly ascertained in 42 patients (50%), with under estimation in 11 patients (13%) and overestimation in 31 patients (37%). Conclusions: After radiochemotherapy, endosonography does not provide a satisfactory accuracy for preoperative staging of rectal cancer. New interpretation and diagnostic criteria are needed for the prediction of treatment response. Received: 28 February 1999/Accepted: 2 April 1999     

The examiner's learning effect and its influence on the quality of endoscopic ultrasonography in carcinoma of the esophagus and gastric cardia

Background: The preoperative diagnosis of tumors of the esophagus and the gastric cardia is an important element in their stage-oriented therapy. The goal of the present study was to evaluate the accuracy of endosonographic ultrasound (EUS) and to test its usefulness in tumor staging and the assessment of operability. Methods: A total of 139 tumors were scanned via EUS by one examiner ≤14 days prior to resection (TNM staging per UICC, 1987). Results: The accuracy for completely traversable tumors was 60.8% for T1, 82.1% for T2, 77.5% for T3, and 33% for T4 stages. This accuracy was somewhat reduced in cases of nontraversable tumor stenosis (51.9%). In T staging, a significant case-dependent improvement in accuracy to 89.5% was found; this was regarded as a learning effect. In N staging, we considered only those tumors that were resected by the transthoracic approach with systematic node dissection and complete EUS (n= 80). N-stage accuracy (T1–T4) was 71.3%, and no improvement could be shown. To assess operability, discrimination between T1/T2 and T3/T4 tumors is crucial. Accuracy, sensitivity, and specifity can thus be improved significantly. Conclusions: The quality of EUS depends on the experience of the examiner. Reliable results can be obtained after >75 examinations have been done. EUS is a valuable tool in tumor staging when it is performed by an experienced examiner or under the direct supervision of such a person. Received: 28 April 1998/Accepted: 14 October 1998     

Minimally invasive surgical staging for esophageal cancer

Background: The incidence of esophageal adenocarcinoma is increasing in the United States, and the 5-year survival rate is dismal. Preliminary data suggest that conventional imaging is inaccurate in staging esophageal cancer and could limit accurate assessment of new treatments. The objective of this study was to compare minimally invasive surgical staging (MIS) with conventional imaging for staging esophageal cancer. Methods: Patients with potentially resectable esophageal cancer were eligible. Staging by conventional methods used computed tomography (CT) scan of the chest and abdomen, and endoscopic ultrasound (EUS), whereas MIS used laparoscopy and videothoracoscopy. Conventional staging results were compared to those from MIS. Results: In 53 patients, the following stages were assigned by CT scan and EUS: carcinoma in situ (CIS; n= 1), I (n= 1), II (n= 23), III (n= 20), IV (n= 8). In 17 patients (32.1%), MIS demonstrated inaccuracies in the conventional imaging, reassigning a lower stage in 10 patients and a more advanced stage in 7 patients. Conclusions: In 32.1% of patients with esophageal cancer, MIS changed the stage originally assigned by CT scan and EUS. Therefore, MIS should be applied to evaluate the accuracy of new noninvasive imaging methods and to assess new therapies for esophageal cancer. Received: 5 April 1999/Accepted: 15 March 2000/Online publication: 12 July 2000     

Comparison of results after transanal endoscopic microsurgery and radical resection for T1 carcinoma of the rectum

Background: We compared the results of transanal endoscopic microsurgery and radical surgery in patients with T1 carcinomas of the rectum. Methods: We performed a retrospective study (1985–96) to compare the results obtained in 103 patients with T1 rectal carcinomas (low-risk T1, n= 80; high-risk T1; n= 23) undergoing transanal endoscopic microsurgery and radical surgical therapy. Results: The complication rate in patients undergoing local excision was 3.4% (two of 58); it was 18% (eight of 45) in the group treated with radical surgery. Two of 45 patients (3.8%) died after radical resection; there were no deaths after local excision. With regard to the actuarial 5-year survival rate, no difference was observed in the group with low-risk T1 carcinoma between patients treated with local excision (79%) and those who had radical resection (81%) (p= 0.72). In patients with high-risk T1 carcinoma, lymph node metastases were identified in four of 11 patients undergoing radical resection (36%). Four of 12 patients with high-risk T1 carcinoma treated by local excision developed recurrences, whereas none of the patients undergoing primary radical surgery had a recurrence. Conclusions: Transanal endoscopic microsurgery for the treatment of low-risk T1 carcinomas is associated with a significantly lower complication rate than radical surgical therapy. There is no difference in 5-year survival between local and radical surgical therapy in patients with low-risk T1 carcinoma. Received: 23 May 1997/Accepted: 18 December 1997     

Minimally invasive surgical biopsy confirms PET findings in esophageal cancer

This report describes our initial experience using positron emission tomography (PET) scanning in esophageal cancer patients. In two patients PET identified distant metastatic disease missed by conventional staging. Laparoscopic biopsy provided histological confirmation of metastases. In the third patient, locoregional lymph nodes were identified by PET and confirmed by surgical staging. In this preliminary report, PET appears to be a promising new noninvasive modality for staging patients with esophageal cancer. Received: 6 December 1997/Accepted: 14 January 1997     

First results of laparoscopic gastrostomy

Background: Laparoscopic gastrostomy as an alternative to open gastrostomy was introduced with various technical variants 5 years ago. However, long-term results of these new methods are still lacking. Methods: From 4/1993 to 2/1996, laparoscopic gastrostomies were performed on 42 patients (50.9 ± 15.6 [24–71] years) with esophageal stenosis in locally advanced hypopharyngeal (17 patients) or oropharyngeal (nine patients) carcinoma, incurable esophageal carcinoma (13 patients) and cerebral dyspagia (three patients). Operating time was 38 ± 11 min [15–65 min]. Procedure-related mortality was 0%. Major complications occurred in 2/42 (4.7%) patients; minor complications were found in 4/42 (9.4%) patients. During a total usage time of 427 months, 14 stoma infections occurred (0.11 infections/100 days). Conclusion: Laparoscopic gastrostomy allows a safe, fast, and cheap reestablishment of enteral nutrition. The procedure is minimally invasive and can also be performed under local anesthesia. It has become our method of choice in patients with malignant, nonresectable subtotal stenosis of the hypopharynx or esophagus. Received: 5 March 1996/Accepted: 31 July 1996     

Laparoscopically assisted transsacral resection of rectal cancer with primary anastomosis

Background: The management of rectal cancer has been changing to include more sphincter-sparing procedures. We report our initial experience with a new technique incorporating laparoscopy and a transsacral approach for low or midlevel rectal cancer. Here, we tried to determine whether this sphincter-sparing method could produce acceptable morbidity and recurrence rates. Methods: Patients with rectal cancer 4 to 8 cm from the dentate line underwent laparoscopically-assisted transsacral resection (LTR) with primary anastomosis. With this technique, the rectosigmoid is mobilized via laparoscopy while the patient is in the supine position. Next, the patient is placed in the prone jackknife position, and a segment of rectum is resected by a transsacral approach. Age, estimated blood loss, length of time in the operating room, length of stay, and postoperative complications were noted. Aspects of the tumor pathology regarding stage, lymph nodes, tumor size, and presence of tumor at resection margins also were recorded. Results: A total of 13 patients, ages 26 to 70 years (mean, 52.5 years), underwent the procedure. No perioperative deaths occurred. The mean hospital stay was 9.6 days. The average size of the rectal lesion was 4.3 cm in the largest dimension. The average specimen contained 11.5 total, and 2.0 metastatic lymph nodes. Postoperative complications included two anastomotic breakdowns and two other wound complications. Late follow-up evaluation ranged from 10 to 30 months, with 11 of 13 patients alive (85% survival). Two local recurrences and three distant recurrences were noted at long-term follow-up assessment. Conclusions: In selected patients with low or midlevel rectal cancer, LTR may be a viable option. Further experience is necessary to define its oncologic efficacy and whether routine temporary diverting colostomy is indicated. Received: 16 June 1999/Accepted: 1 November 1999/Online publication: 12 July 2000     

Is laparoscopic sonography a reliable and sensitive procedure for staging colorectal cancer?

Background: Laparoscopic colectomy has developed rapidly with the explosion of technology. In most cases, laparoscopic resection is performed for colorectal cancer. Intraoperative staging during laparoscopic procedure is limited. Laparoscopic ultrasonography (LUS) represents the only real alternative to manual palpation during laparoscopic surgery. Methods: We evaluated the diagnostic accuracy of LUS in comparison with preoperative staging and laparoscopy in 33 patients with colorectal cancer. Preoperative staging included abdominal US, CT, and endoscopic US (for rectal cancer). Laparoscopy and LUS were performed in all cases. Pre- and intraoperative staging were related to definitive histology. Staging was done according to the TNM classification. Results: LUS obtained good results in the evaluation of hepatic metastases, with a sensitivity of 100% versus 62.5% and 75% by preoperative diagnostic means and laparoscopy, respectively. Nodal metastases were diagnosed with a sensitivity of 94% versus 18% with preoperative staging and 6% with laparoscopy, but the method had a low specificity (53%). The therapeutic program was changed thanks to laparoscopy and LUS in 11 cases (33%). In four cases (12%), the planned therapeutic approach was changed after LUS alone. Conclusions: The results obtained in this study demonstrate that LUS is an accurate and highly sensitive procedure in staging colorectal cancer, providing a useful and reliable diagnostic tool complementary to laparoscopy. Received: 2 May 1997/Accepted: 11 February 1998     

The role of laparoscopy in preoperative staging of esophageal cancer

Background: Diagnostic laparoscopy has been used to determine resectability and to prevent unnecessary laparotomy in patients with advanced esophageal cancer. The objective of this prospective study was to evaluate the role of laparoscopy in conjunction with computed tomography (CT) scan in staging patients with esophageal cancer. Methods: From March 1995 to October 1998, 59 patients with biopsy-proven esophageal cancer underwent diagnostic laparoscopy with concurrent vascular access device and feeding jejunostomy tube placement. Results: Laparoscopy changed the treatment plan in 10 of 59 patients (17%). Of the patients with normal-appearing regional or celiac nodes, 78% were confirmed by biopsy to be tumor free, whereas 76% of patients with abnormal-appearing nodes were confirmed by biopsy to have node-positive disease. Conclusions: Diagnostic laparoscopy is useful for detecting and confirming nodal involvement and distant metastatic disease that potentially would alter treatment and prognosis in patients with esophageal cancer. Received: 16 May 1999/Accepted: 10 November 1999/Online publication: 24 March 2000     

The role of staging laparoscopy for multimodal therapy of gastrointestinal cancer

Background: This prospective study was conducted to evaluate the accuracy and the therapeutic relevance of staging laparoscopy. Methods: Between June 1993 and February 1997 staging laparoscopy was performed in 389 patients with various neoplasms. Additionally, 144 selected patients of this group were examined with laparoscopic ultrasound using a semiflexible ultrasound probe (7.5 MHz). Results: Compared to conventional imaging methods, laparoscopy and laparoscopic ultrasound improved the accuracy of staging in 158 of 389 patients (41%). Statistical subgroup analysis of 131 patients with gastric cancer showed that the accuracy of staging laparoscopy in the detection of distant metastases (68%) was significantly higher (p < 0.01) than that of ultrasound (63%) or computed tomography (58%). In the whole group, laparoscopy alone disclosed intraabdominal tumor dissemination or nonresectable disease in 111 patients. Laparoscopic ultrasound displayed additional metastases—i.e., liver metastases (n = 9), M1 lymph nodes (n = 15), or nonresectable tumors (n = 6) in 30 patients. Although metastastic disease was suggested by preoperative imaging, benign lesions were found in five patients with laparoscopy and in a further 12 patients with ultrasonography. The findings of staging laparoscopy changed the treatment strategy in 45% of the patients. Conversion to open surgery was necessary in 5% of the cases, and complications related to laparoscopy occured in 4% of the patients. Conclusions: Laparoscopy with laparoscopic ultrasound improves the staging of gastrointestinal tumors and has a significant impact on a stage-adapted surgical therapy. Received: 3 April 1997/Accepted: 26 September 1997