Upper abdominal stop-flow perfusion as a neo and adjuvant hypoxic regional chemotherapy for resectable gastric carcinoma. A prospective randomized clinical trial.

BACKGROUND/AIMS: Gastric cancer remains a disease with a poor and dismal prognosis even after radical surgical resection. The present study attempts to clarify whether neo and adjuvant hypoxic upper abdominal chemotherapy can improve the survival of patients with gastric cancer undergoing radical surgical resection. Patterns of failure after surgery for gastric cancer include peritoneal seeding, resection margin recurrence, and liver metastasis. METHODOLOGY: From October 1995 to February 1999, 58 patients with resectable gastric cancer were randomly assigned to three groups. Hypoxic upper abdominal chemotherapy was carried out using Mitomycin-C, 5-Fluorouracil, Leucovorin, and Farmorubicin, 10 days before surgery, and 20 days following surgery, in Group A (n=20) with or without in Group B (n=19) systemic chemotherapy; the remaining patients (Group C: n=19) had neither neo nor adjuvant treatment. RESULTS: The 4-year survival of Group C patients was 29.2%. Group A patients (surgery plus hypoxic neo and adjuvant chemotherapy and systemic chemotherapy) had a 4-year survival of 45.5% versus a 4-year survival of 39.2% of Group B patients (surgery and hypoxic neo and adjuvant abdominal perfusion). Patients of all stages, histologically confirmed, were included in this study. CONCLUSIONS: Patients suffering from gastric carcinoma have demonstrated statistically improved survival by combining resectional surgery with neo and adjuvant hypoxic upper abdominal perfusion and adjuvant systemic chemotherapy.     

A short course of preoperative radiotherapy improves prognosis of operable rectal carcinoma: a case control study

BACKGROUND/AIMS: Randomized Swedish studies demonstrate the efficacy of a 5-fraction course of preoperative radiotherapy for rectal carcinoma. The present study evaluates the results in a single Greek institution over a 10-year period, with a similar regimen. METHODOLOGY: During the period of 1995-2000, 150 consecutive patients with Dukes' B or C rectal cancer were matched to receive preoperative radiotherapy (Group I) or not (Group II). Seventy-five patients received pelvic radiotherapy of 2500cGY/5 fractions, followed by surgery within one week. Radiotherapy was delivered through 4 portals, with the patient lying in the prone position. A CT scan was used to define treatment volume. The 5-fraction course was used for lesions that seemed readily resectable. Patients in both groups received adjuvant chemotherapy. Local recurrence, disease-free interval and 5-year survival were evaluated and analyzed. RESULTS: The disease-free interval was significantly longer in Group I (p < 0.0005). This benefit was mainly due to a significantly lower incidence of local recurrence in Group I (9/75, 12%) compared with Group II (30/75, 40%) (p < 0.0005). The incidence of distant metastases was not significantly different between the 2 groups. The 5-year survival for all patients, who underwent "curative" surgery was significantly higher in Group I (77.3%) as compared to Group II (39%), (p < 0.0005). CONCLUSIONS: Patients with resectable rectal cancer who received 2500cGy/5 fractions preoperative radiotherapy to the pelvis had excellent local control of disease, longer disease-free interval and higher 5-year survival than patients who did not. These patients were able to undergo sphincter preserving surgery and adjuvant chemotherapy.     

Changing trends in the management of Klatskin tumor

BACKGROUND/AIMS: To evaluate the long-term outcome of a multidisciplinary approach for advanced Klatskin tumor involving the hepatic hilus. METHODOLOGY: A retrospective analysis was undertaken in 110 patients between 1993 and 2003. The patients were divided into Group A (n=42) and Group B (n=58). Group A patients underwent local excision of the tumor and Group B patients underwent combined tumor and liver resection with or without resection of the regional vascular structures. On admission, all patients underwent percutaneous transhepatic biliary drainage. Where hepatectomy was planned, portal vein branch ligation and transection was done ipsilateral to the liver lobe where the tumor was present. An arterial catheter was introduced into the hepatic artery at the end of the surgery, for adjuvant locoregional immunochemotherapy, which was carried out in all patients. The second-stage resectional surgery was carried out 35 days later. RESULTS: The overall mean survival for Group A patients was 29 months (range 14 to 76). The mean disease-free survival was 28 months (range 10-52). Five-year survival rate was 5% and five-year disease-free survival was 0%. The overall mean survival for Group B patients was 39 months (range 28 to 79). The mean disease-free survival was 32 months (range 17-72). Five-year survival rate was 20% and five-year disease-free survival was 10%. CONCLUSIONS: The concept of a multidisciplinary approach has significantly improved survival in patients with a grave disease like Klatskin tumor.     

Is there a role for adjuvant chemotherapy in pathological complete response rectal cancer tumors following neoadjuvant chemoradiotherapy?

Purpose

To investigate the contribution of neoadjuvant chemotherapy in rectal cancer patients with pathological complete response (pCR).

Methods

Data were collected on all consecutive locally advanced rectal cancer patients treated with neoadjuvant chemotherapy and later resected in our institution between 2001 and 2013. Surgery was performed by a single proctology team, and tumor specimens were evaluated by the hospital pathologists.

Results

The medical records of 260 patients were analyzed, and 54 patients of those patients were found to have achieved pCR (20.8 %). Two of those patients were lost to follow-up. Thirty-five of the 54 pCR patients received adjuvant chemotherapy (Group A) and 17 did not (Group B). With the sole exception of the Group A patients being younger than the Group B patients (60.9 ± 11.9 vs. 68.7 ± 10.8 years, respectively, p = 0.0272), all other evaluated parameters were identical between the two groups. There was no advantage for the administration of adjuvant chemotherapy for disease-free survival (DFS) and overall survival (OS).

Conclusions

Adjuvant chemotherapy played no part in disease-free survival and OS of patients with rectal cancer who had been treated with neoadjuvant chemotherapy and achieved pCR. Our findings indicate a tendency for adjuvant chemotherapy to be administered to younger rectal cancer patients. A randomized trial should be conducted to resolve the question of whether they derive any benefit from it.     

Mono-bloc total spleno-pancreaticoduodenectomy for pancreatic head carcinoma with portal-mesenteric venous invasion. A prospective randomized study

BACKGROUND/AIMS: To evaluate, the early and long-term results of mono-bloc spleno-pancreatic and vascular resection for advanced carcinoma of the head of the pancreas, with portal-mesenteric venous invasion. METHODOLOGY: In a prospective, randomized trial, fifty-six patients with advanced carcinoma of the head of the pancreas with vascular invasion were studied. Patients were randomly divided in two groups A and B. Group A patients underwent an en-bloc spleno-pancreatic and vascular resection. Group B patients underwent a palliative gastro-biliary bypass. Patients in both groups were subjected to adjuvant locoregional chemoimmunotherapy, through an arterial catheter introduced into the superior mesenteric artery via a jejunal arterial branch. RESULTS: The 2- and 5-year survival rates for Group A patients were 81.8% and 18.5%. The respective percentages for disease-free survival were 60.6% and 0%. Two-year survival for group B was nil. CONCLUSIONS: Mono-bloc spleno-pancreaticoduodenectomy and regional vascular resection and reconstruction, with adjuvant locoregional chemoimmunotherapy leads to substantial prolongation of survival and optimization of quality of life.     

Surgical treatment of rectal cancer: results of a strategy for selective preoperative radiotherapy

AIM: The indications for preoperative adjuvant therapy in rectal cancer are still a subject of debate. The objective of this study was to analyze the results of surgical resection and selective radiotherapy in a group of high-risk patients (Dukes B and C) taken from a series of 148 consecutive patients with rectal cancer. METHODS: All patients with rectal cancer considered for resection during the period 1994-2004 were prospectively included. The policy was to deliver preoperative radiotherapy in cases of fixed or tethered tumors or when imaging predicted T3 tumors with positive circumferential margins. Other tumors were resected without neoadjuvant therapy. All resections were done using the total mesorectal excision (TME) technique. RESULTS: One hundred and forty-eight consecutive patients underwent rectal resection during the study period. A sphincter-saving technique was carried out in 134 patients (90%). No patient was excluded from the analysis. The perioperative mortality was 2/148 (1.5%). Curative surgery was obtained in 135 patients. The 94 patients with a Dukes B or C tumor formed the high-risk group that was the basis of our study. The mean follow-up in this group was 58 months (range 24-120). Twenty patients (21%) received preoperative radiotherapy (PRT) and 74 (79%) underwent surgical resection alone. A positive circumferential margin, defined as one that was < or =1 mm, was found in seven of the 85 patients (8.2%) for whom this measure was available. The actuarial five-year overall survival was 74%. Local recurrence developed in eight patients (8.4%): four in the PRT group (20%), and four in the non-PRT group (5.4%). Only two patients developed an isolated local recurrence. CONCLUSIONS: Preoperative adjuvant therapy can be safely omitted in patients who demonstrate clear circumferential margins on preoperative imaging, provided that adequate surgery is subsequently performed.     

Outcome of Anterior Resection for Stage II Rectal Cancer Without Radiation: The Role of Adjuvant Chemotherapy

BACKGROUND This study aimed to evaluate the oncological outcome of patients who had Stage II rectal cancer and underwent curative nonsphincter-ablation surgery without adjuvant radiation.PATIENTS AND METHODS During the study period from August 1993 to December 2002, 224 patients (141 men) with Stage II cancer underwent curative anterior resection or Hartmanns procedure without adjuvant radiation. Data were collected prospectively. The oncologic outcomes of these patients were studied and the risk factors for recurrence and survival were analyzed.RESULTS The median age of the patients was 69 (range, 27–89) years and the median level of the tumor from the anal verge was 8 (range, 3–20) cm. Four patients (1.8 percent) died in the postoperative period and postoperative complications occurred in 74 patients (33 percent). The median follow-up time of the surviving patients was 43.6 months. The actuarial five-year recurrence rate was 25.4 percent, whereas the five-year actuarial local and systemic recurrence rates were 6.1 percent and 20 percent, respectively. On multivariate analysis, independent factors associated with a higher recurrence rate included lymphovascular invasion, perineural invasion, and absence of chemotherapy. The overall and cancer-specific survival rates of the patients were 71.1 percent and 81.1 percent, respectively. On multivariate analysis, only adjuvant chemotherapy (P = 0.024; hazard ratio = 6.04; 95 percent confidence interval, 1.27–28.74) and the absence of lymphovascular invasion (P = 0.002; hazard ratio = 3.77; 95 percent confidence interval, 1.63–8.77) were independent factors associated with significantly better cancer-specific survival.CONCLUSION A low local recurrence rate can be achieved in patients with Stage II rectal cancer treated with nonsphincter-ablation surgery without adjuvant radiation. Postoperative chemotherapy is associated with a lower recurrence rate and higher survival rates. Further study is warranted to define the role of adjuvant chemotherapy in patients with rectal cancer.© The American Society of Colon and Rectal SurgeonsPublished online: 28 January 2005.     

Role of surgery in a case-control study of patients with clinical stage IIIA small cell lung cancer

BackgroundThe role of surgery in the multidisciplinary treatment of clinical stage IIIA small cell lung cancer is yet to be verified. This study was performed to determine the benefit of surgery in patients with stage IIIA small cell lung cancer.MethodsPatients diagnosed with stage IIIA small cell lung cancer at Shanghai Pulmonary Hospital from 2005 to 2015 were included and divided into two groups: the surgery with neoadjuvant and adjuvant chemotherapy group and the concurrent chemo-radiotherapy group. Overall survival was compared between the two groups. A multivariate Cox regression model was constructed to evaluate factors associated with overall survival.ResultsOf 69 patients with stage IIIA small cell lung cancer during the study period, 40 patients (58%) underwent surgery with neoadjuvant and adjuvant chemotherapy, and 29 patients (42%) underwent concurrent chemo-radiotherapy. Patients in the surgery with neoadjuvant and adjuvant chemotherapy group had a longer overall survival compared with patients in the concurrent chemo-radiotherapy group (median survival: 33.1 vs. 16.2 months, respectively; 2-year overall survival: 44.2% vs. 14.9%, respectively; log-rank: P=0.045). A multivariate analysis revealed that surgery with neoadjuvant and adjuvant chemotherapy (hazard ratio: 0.374; 95% confidence interval: 0.173–0.808, P=0.012) was independently associated with overall survival.ConclusionsPatients with stage IIIA small cell lung cancer treated with surgical resection plus chemotherapy demonstrated longer overall survival compared with those who underwent concurrent chemo-radiotherapy. Surgery may be an option for clinical stage IIIA small cell lung cancer after induction chemotherapy in selected patients.     

Adjuvant therapy sparing in rectal cancer achieving complete response after chemoradiation

AIM: To evaluate the long-term results of conventional chemoradiotherapy and laparoscopic mesorectal excision in rectal adenocarcinoma patients without adjuvant therapy.METHODS: Patients with biopsy-proven adenocarcinoma of the rectum staged cT3-T4 by endoscopic ultrasound or magnetic resonance imaging received neoadjuvant continuous infusion of 5-fluorouracil for five weeks and concomitant radiotherapy. Laparoscopic surgery was planned after 5-8 wk. Patients diagnosed with ypT0N0 stage cancer were not treated with adjuvant therapy according to the protocol. Patients with ypT1-2N0 or ypT3-4 or N+ were offered 5-fluorouracil-based adjuvant treatment on an individual basis. An external cohort was used as a reference for the findings.RESULTS: One hundred and seventy six patients were treated with induction chemoradiotherapy and 170 underwent total mesorectal excision. Cancer staging of ypT0N0 was achieved in 26/170 (15.3%) patients. After a median follow-up of 58.3 mo, patients with ypT0N0 had five-year disease-free and overall survival rates of 96% (95%CI: 77-99) and 100%, respectively. We provide evidence about the natural history of patients with localized rectal cancer achieving a complete response after preoperative chemoradiation. The inherent good prognosis of these patients will have implications for clinical trial design and care of patients.CONCLUSION: Withholding adjuvant chemotherapy after complete response following standard neoadjuvant chemoradiotherapy and laparoscopic mesorectal excision might be safe within an experienced multidisciplinary team.     

Role of follow-up in management of local recurrences of colorectal cancer

PURPOSE: This prospective, randomized, single-center study was designed to evaluate the influence of follow-up on detection and resectability of local recurrences and on survival after radical surgery for colorectal cancer. METHODS: Between 1987 and 1990, 207 consecutive patients who underwent curative resections for primary untreated large-bowel carcinoma were randomly assigned to a conventional follow-up group (Group A; n=103) and to an intense follow-up group (Group B; n=104). All the patients were followed up prospectively, and the outcome was known for all of them at five years. Patients in Group A were seen at six-month intervals for one year, and once a year thereafter. Patients in Group B were checked every three months during the first two years, at six-month intervals for the next three years, and once a year thereafter. RESULTS: Of the 103 patients in Group A, local recurrence was detected in 20; 9 (13 percent) of these patients had colon cancer, and 11 (29 percent) had rectal cancer. Of the 104 patients in Group B, local recurrence was detected in 26; 12 (16 percent) of these patients had colon cancer, and 14 (45 percent) had rectal cancer. Twelve cases (60 percent) of local recurrence in Group A and 24 cases (92 percent) in Group B were detected at scheduled visits (P<0.05). Local recurrences were detected earlier in patients of Group B (10.3±2.7vs. 20.2±6.1 months;P<0.0003). Curative re-resection was possible in 2 patients (10 percent) in Group A, 1 with colon cancer and 1 with rectal cancer, and in 17 patients (65 percent) in Group B, 6 with colon cancer and 11 with rectal cancer (P<0.01). Of the Group B patients who had curative re-resections of local recurrence, 8 (47 percent) were disease-free and long-term survivors as of the last follow-up, and 2 (11.7 percent) were alive, but with a new recurrence. The 2 patients in Group A who had curative re-resections died as a result of cancer. The five-year survival rate in Group A was 58.3 percent and in Group B was 73.1 percent. The difference is statistically significant (P < 0.02). CONCLUSIONS: Our data support use of an intense follow-up plan after primary resection of large-bowel cancer, at least in patients with rectal cancer.     

Adjuvant radiotherapy following total mesorectal excision for stage IIA rectal cancer: is it beneficial?

Purpose  

The benefit of adjuvant radiotherapy in patients with stage IIA (T3N0) rectal cancer following total mesorectal excision (TME) is controversial. We evaluated the effect of adjuvant chemoradiotherapy (CRT) versus chemotherapy (CT) alone on the local recurrence and survival of patients with stage IIA rectal cancer after TME.     

The clinical efficacy of adjuvant systemic chemotherapy with gemcitabine in node-positive pancreatic cancer

BACKGROUND/AIMS: The effects of gemcitabine in postoperative adjuvant chemotherapy were evaluated in patients suffering from locally advanced pancreatic cancer with lymph node metastases. The results were compared with those of our historical control patients treated by surgery alone. METHODOLOGY: Twenty-one patients with node-positive pancreatic cancer who had undergone a pancreatic resection with curative intent over the five years up to February 2003, were enrolled in this study. Nine cases received postoperative adjuvant chemotherapy with biweekly administration of 1000 mg/m2 gemcitabine, while the remaining 12 cases underwent surgery without any adjuvant chemotherapy. RESULTS: The chemotherapy was well tolerated with only mild symptomatic and hematologic toxicities. The overall cumulative survival rates of the chemotherapy and surgery-alone groups were 86% and 75% at one year, and 50% and 0% at two years, with a median survival of 20.3 months and 15.4 months, respectively (p=0.0084). The disease-free interval was also significantly greater in the chemotherapy group compared with the surgery-alone group (p=0.0244). CONCLUSIONS: Adjuvant systemic chemotherapy utilizing gemcitabine was feasible with acceptable adverse effects and improved the survival rate of patients with node-positive pancreatic cancer. Although further investigation is needed to confirm these results, gemcitabine is a promising agent for the treatment of resectable advanced pancreatic cancer.     

Pelvic Exenteration and Sacral Resection for Locally Advanced Primary and Recurrent Rectal Cancer

PURPOSE: The only possibility of a surgical cure in patients with locally advanced primary or recurrent rectal cancer would be an extended resection such as pelvic exenteration and sacral resection. The aim of this study was to evaluate the safety, tolerability, and survival benefits of these procedures. METHODS: Between 1988 and 1999, 64 patients with locally advanced primary or recurrent rectal cancer underwent abdominoperineal resection, with sacral resection in 9 patients, anterior pelvic exenteration in 8 patients, total pelvic exenteration in 27 patients, and total pelvic exenteration with sacral resection in 20 patients. RESULTS: Rates of morbidity, reoperation, and mortality were 50, 4.5, and 0 percent in 22 patients with primary cancer, and 60, 2.4, and 2.4 percent in 42 patients with recurrent disease, respectively. Major complications, such as sepsis, intra-abdominal abscess, and enteric fistula caused one hospital death and reoperation in two patients. In 21 patients who underwent curative resection for primary cancer, the overall five-year survival rates were 74.1 percent for Dukes B and 47.4 percent for Dukes C, although the difference was not statistically significant. Thirty patients with recurrent cancer who underwent curative resection had significantly improved survival, with a five-year survival rate of 22.9 percent, compared with 12 patients who underwent palliative resection, resulting in a survival rate of 0 percent (P = 0.0065). CONCLUSIONS: Pelvic exenteration and sacral resection for primary or recurrent rectal cancer are tolerable procedures with a low mortality rate. Although they provide a survival benefit if curative resection is possible, the associated morbidity remains high and should be followed up closely.     

Esophagectomy for locally advanced esophageal cancer, followed by chemoradiotherapy and adjuvant chemotherapy

AIM: To compare the efficacy and toxicity of a three-step combination therapy with post-operative radiation alone for locally advanced esophageal cancer. METHODS: Patients with T3-4 and NO-1 esophageal carcinoma from a number of institutions were non-randomly, prospectively enrolled in the study. All patients underwent single-stage curative en bloc esophagectomy. The patients were then assigned into one of two treatment groups based on treatment consisting of either post-operative concurrent chemoradiotherapy (CCRT) with weekly cisplatin 30 mg/m~2 followed by systemic adjuvant chemotherapy (four monthly cycles of cisplatin 20 mg/m~2 and 5-fluorouracil 1000 mg/m~2 for five consecutive days), or, post-operative radiation alone. The radiotherapy dose was 55-60 Gy for all patients. Primary end-point of this study was to assess the per-protocol patients' improvement of overall survival benefit. Secondary end-point was designed to evaluate both the per-protocol and intent-totreat patients' outcome of survival. RESULTS: A total of 60 patients (n=30 per group) were enrolled in this study. The two groups were generally comparable for demographic characteristics and hematologicai and non-hematological toxicities. The CCRT with weekly cisplatin was well tolerated, with significantly better overall survival (30.9 mo vs 20.7 mo; 95% CI, 27.5-36.4 vs 15.2-26.1) and 3-year survival (70.0% vs 33.7%; P=0.003). Low histological grade of tumor (P<0.001) was associated with favorable survival in these locally advanced patients. CONCLUSION: For locally advanced esophageal cancer, the combination of esophagectomy, post-operative CCRT with weekly cisplatin and systemic adjuvant chemotherapy is well tolerated and effective. A large-scale, prospective randomized trial of this regimen is in progress.     

Outcome of Total Pelvic Exenteration for Primary Rectal Cancer

PURPOSE: This retrospective study identifies the clinicopathologic factors (age, gender, size of tumor, location, tumor stage, lymph node metastasis, histologic differentiation, and adjuvant therapies) that are useful in predicting long-term survival in patients undergoing total pelvic exenteration for advanced primary rectal cancer. METHODS: We reviewed the medical records of 71 patients with stage T3 or T4 primary rectal cancer who underwent a curative total pelvic exenteration. The effects of various clinical variables on long-term survival were analyzed. RESULTS: The postoperative mortality, hospital death, and morbidity rates were 1.4, 4.2, and 66.2 percent, respectively. The overall five-year survival rate after total pelvic exenteration was 54.1 percent. The five-year survival rate was 65.7 percent for patients with T3 lesions and 39 percent for patients with T4 lesions. A univariate analysis showed that postoperative survival was affected by age, tumor stage, and lymph node metastasis, while a multivariate analysis showed that age and lymph node metastasis were independent prognostic factors. CONCLUSION: Total pelvic exenteration may enable long-term survival in younger patients with stage T3 or T4 primary rectal cancer and little or no lymph node metastasis.     

Oncologic outcomes of primary and post-irradiated early stage rectal cancer: a retrospective cohort study

AIM： To evaluate the oncologic outcomes of primary and post-irradiated early stage rectal cancer and the effectiveness of adjuvant chemotherapy for rectal cancer patients. METHODS： Eighty-four patients with stage Ⅰ rectal cancer after radical surgery were studied retrospectively and divided into ypstage Ⅰ group （n = 45） and pstage Ⅰ group （n = 39）, according to their preoperative radiation, and compared by univariate and multivariate analysis. RESULTS： The median follow-up time of patients was 70 mo. No significant difference was observed in diseaseprogression between the two groups. The 5-year disease-free survival rate was 84.4% and 92.3%, respectively （P = 0.327） and the 5-year overall survival rate was 88.9% and 92.3%, respectively, for the two groups （P = 0.692）. The disease progression was not significantly associated with the pretreatment clinical stage in ypstage Ⅰ group. The 5-year disease progression rate was 10.5% and 19.2%, respectively, for the patients who received adjuvant chemotherapy and for those who rejected chemotherapy in the ypstage Ⅰ group （P = 0.681）. CONCLUSION： The oncologic outcomes of primary and post-irradiated early stage rectal cancer are similar. Patients with ypstage Ⅰ rectal cancer may slightly benefit from adjuvant chemotherapy.     

Efficacy of extended lymphadenectomy in the noncurative gastrectomy for advanced gastric cancer.

BACKGROUND/AIMS: We retrospectively analyzed clinicopathologic data on 83 patients with advanced gastric cancer who underwent noncurative gastrectomy, with respect to the relation between the extent of lymphadenectomy and survival benefit. METHODOLOGY: These 83 patients were divided into 44 patients with limited or simple lymph node dissection (D0 in 14 and D1 in 30: Group A) and 39 patients with extended lymph node dissection (D2: Group B). RESULTS: The 1-year survival rate in Group B (82.1%) was significantly higher than in Group A (49.0%). However, the 3-year and 5-year survival rates did not significantly differ between Group A versus Group B, 39.7% versus 25.7% and 39.7% versus 20.5%, respectively. Median survival time after surgery with and without distant metastasis in Group B (21.5 months) was longer than in Group A (16.4 months), although not significant. CONCLUSIONS: While gastrectomy with extended lymphadenectomy did not contribute to improve long-term survival in patients with noncurable advanced gastric cancer, the utility of extended lymph node dissections may be relevant to improved locoregional control, at least in the prognosis within 1 year after surgery. Not only extended lymphadenectomy but also aggressive chemotherapy may be needed to improve the long-term survival for such patients.     

Sphincter-preserving R0 total mesorectal excision with resection of internal genitalia combined with pre- or postoperative chemoradiation for T4 rectal cancer in females

AIM: To evaluate the impact of chemoradiation admi-nistered pre- or postoperatively on prognosis in females following R0 extended resection with sphincter-preserving total mesorectal excision (TME) for locally advanced rectal cancer and to assess the association between chemoradiation and intra- and postoperative variables. METHODS: Twenty-one females were treated for locally advanced but preoperatively assessed as primarily resectable rectal cancer involving reproductive organs. Anterior resection with TME and excision of internal genitalia was combined with neo- or adjuvant chemoradiation. Two-year disease-free survival analysis was performed with the Kaplan-Meier method and log-rank test. The association between chemoradiation and other variables was evaluated with the Fisher's exact test and Mann-Whitney test. RESULTS: Survival rate decreased in anaemic females (51.5% vs 57.4%), in patients older than 60 years (41.8% vs 66.7%) with poorly differentiated cancers (50.0% vs 55.6%) and tumors locatedor=1 L, rate of postoperative bladder and anorectal dysfunction, and minimal distal resection margin. It significantly influenced minimal radial margin (mean 4.2 mm vs 1.1 mm; P<0.01). CONCLUSION: Despite involving internal genitalia, long-term disease-free survival and sphincter preservation may be achieved with combined-modality therapy for females with T4 locally advanced rectal carcinoma. Neoadjuvant chemoradiation does not compromise functional results and may significantly improve oncological outcomes probably due to enhanced radial clearance.     

Management of recurrent rectal cancer： A population based study in greater Amsterdam

AIM： To analyze, retrospectively in a populationbased study, the management and survival of patients with recurrent rectal cancer initially treated with a macroscopically radical resection obtained with total mesorectal excision （TME）.
METHODS： All rectal carcinomas diagnosed during 1998 to 2000 and initially treated with a macroscopically radical resection （632 patients） were selected from the Amsterdam Cancer Registry. For patients with recurrent disease, information on treatment of the recurrence was collected from the medical records.
RESULTS： Local recurrence with or without clinically apparent distant dissemination occurred in 62 patients （10%）. Thirty-two patients had an isolated local recurrence. Ten of these 32 patients （31%） underwent radical re-resection and experienced the highest survival （three quarters survived for at least 3 years）. Eight patients （25%） underwent non-radical surgery （median survival 24 rno）, seven patients （22%） were treated with radio- and/or chemotherapy without surgery （median survival 15 mo） and seven patients （22%） only received best supportive care （median survival 5 too）. Distant dissemination occurred in 124 patients （20%） of whom 30 patients also had a local recurrence. The majority （54%） of these patients were treated with radio- and/or chemotherapy without surgery （median survival 15 mo）. Twenty-seven percent of these patients only received best supportive care （median survival 6 mo）, while 16% underwent surgery for their recurrence. Survival was best in the latter group （median survival 32 mo）.
CONCLUSION： Although treatment options and survival are limited in case of recurrent rectal cancer after radical local resection obtained with TME, patients can benefit from additional treatment, especially if a radical resection is feasible.     

YpN0 rectal cancer patients with sterilized lymph nodes after neoadjuvant chemoradiotherapy are of greater risk of recurrence

BackgroundIndication for adjuvant chemotherapy in ypN0 rectal cancer patients after chemoradiotherapy (CRT) is debated. The clinical significance of the presence of sterilized lymph nodes (LNS) in ypN0 patients remains to be determined.AimsTo assess the prognostic value of LNS in ypN0 rectal cancers after neoadjuvant CRT.MethodsFrom 2006-2016, 235 patients underwent TME surgery for non-metastatic mid-low rectal cancer after CRT. A lymph node was considered sterilized if there were signs of treatment response (fibrosis, necrosis or mucus) without residual tumor cells.Results180 patients (77%) were classified ypN0 and 55 (23%) ypN+. LNS was present in 20 patients (9%). In ypN0 patients, 5-year OS was similar between patients with and without LNS. In contrast, 5-year DFS was significantly lower in ypN0/LNS + patients (58% vs. 78%, p = 0.043) and was similar to those staged ypN+. In multivariate analysis, two factors were independent predictors of DFS: mesorectal grading (OR = 3.14; 95%CI: 1.10-8.34; p = 0.033) and the presence of LNS (OR = 3.93, 95% CI: 1.06-11.81, p = 0.042)ConclusionThe presence of LNS in ypN0 rectal cancer after neoadjuvant CRT is associated with an increased risk of recurrence and may be taken into account for the discussion of adjuvant chemotherapy.