Surgical management of locoregional recurrence of gastric carcinoma

About half of the patients with gastric cancer subjected to total gastrectomy in curative intention die of recurrence within a few years. Most of these local recurrences occur in the first 2 years postoperatively. In an historic analysis 133 patients of the years 1985-1997 were investigated. Local recurrence was observed in 29 cases within 60 months on average. An intensive follow-up will not affect the long-term outcome of local recurrence. Improved results may be expected only if more effective therapeutic strategies for local recurrence will be developed.     

Therapy results of locoregional recurrences in rectal cancer

Despite of advanced surgical technique and multimodality therapy results following secondary resection of local recurrence after rectal cancer are discussed controversially. PATIENTS AND METHODS: Between 1990 and 1999 81 patients with local recurrence of rectal cancer were treated at our surgical department. Median age was 63 years, 62 % of patients were male. 98 % of recurrences were in local advanced stage (74 % = rT4, 25 % = rT3), 44 % of patients had synchronous distant metastases. RESULTS: 32 patients underwent resection of recurrent rectal cancer. Potential curative surgery was possible in 56 % of resections. Extended resections of adjacent organs were necessary in 21 patients. The 4-year survival in the curative group was 44 % compared to 19 % in patients with microscopic or gross residual disease. CONCLUSION: Optimistic long-term results in recurrent rectal cancer can only be achieved after curative resection. Preoperative radiochemotherapy in advanced cancers increases curative resection and probably survival rate.     

乳腺癌孤立性局部区域复发的诊断和治疗

乳腺癌孤立性局部区域复发受多种危险因素影响,虽然预示着随后可能出现远处转移,然而经过规范的诊断和治疗,仍可获得较好的局部控制率和远期生存率。其复发具有较大的临床异质性,因而治疗也应根据不同的情况选择合理的局部治疗和全身治疗手段,达到改善患者生活质量和提高远期生存的目的。     

Aggressive management of patients with extrahepatic and intrahepatic recurrences of hepatocellular carcinoma by combined resection and locoregional therapy

BACKGROUND: Resection of hepatocellular carcinoma (HCC) is associated with a high incidence of recurrence. Aggressive management of recurrence is an important strategy in prolonging survival. This study evaluated the role of combined resection and locoregional therapy in the management of selected patients with extrahepatic and intrahepatic recurrences. STUDY DESIGN: From a prospective database of 399 patients with hepatectomy for HCC from 1989 to 1998, 63 patients were identified with extrahepatic and intrahepatic recurrences either concurrently or sequentially. Survival outcomes of patients who underwent resection of extrahepatic recurrence and re-resection or locoregional therapy for intrahepatic recurrence were evaluated. RESULTS: Ten patients underwent resection of solitary extrahepatic recurrence and locoregional therapy for intrahepatic recurrence. Transarterial chemoembolization was the main treatment modality for intrahepatic recurrence. Two of these patients also underwent re-resection of intrahepatic recurrence at the time of resection of extrahepatic metastasis. Median survival after recurrence of these 10 patients was 44.0 months (range 18.6 to 132.9 months), and the median overall survival from initial hepatectomy was 49.0 months (range 21.6 to 134.6 months). In contrast, median survival after recurrence of the remaining 53 patients with extrahepatic and intrahepatic recurrences treated by nonsurgical means (locoregional therapy, systemic chemotherapy, or hormonal therapy) was only 10.6 months (p = 0.002). CONCLUSIONS: Aggressive management with combined resection of isolated extrahepatic recurrence and re-resection or locoregional therapy for intrahepatic recurrence may offer longterm survival in selected patients who develop both intrahepatic and extrahepatic recurrences after hepatectomy for HCC.     

结直肠癌肝及肝外转移外科治疗策略

根治性切除是结直肠癌肝转移唯一有治愈希望的治疗方法。如何提高根治性切除率成为结直肠癌肝转移治疗的主要研究方向。目前认为肝转移灶能否切除不是决定于要切除的部分而是决定于拟保留的肝组织,既要全部切除所有癌灶(R0),又要保留足够的残肝功能,残肝流入、流出道与胆管良好。结直肠癌合并肝脏转移是否同期手术仍存在争议,越来越多的学者认为在不进行较大的肝切除时,同期手术对患者有利。手术切除的边界不再强调"1cm原则",而是强调切缘阴性。以奥沙利铂为基础的新辅助化疗可以使40%原本无手术机会的患者得到根治性切除。合并肝外病变(肺、肝门淋巴结,腹腔转移)时不全是手术禁忌证。肝转移术后复发的再切除长期生存率与首次切除类似。世界许多国家正在制定循证医学基础上的结直肠癌肝转移外科治疗规范。现将结直肠癌肝转移外科治疗策略作一综述。     

Surgical treatment of local recurrences of breast carcinoma in the skin and subcutaneous tissues.

Twenty-six cases of local recurrence of breast carcinoma in the skin and subcutaneous tissues after treatment with radical excision and large skin grafts or reconstruction are presented. Seventy-seven per cent of the patients were alive 2 years after the treatment. As a chest wall recurrence of breast cancer in the absence of distant metastases does not always indicate a generalization of the disease, radical reconstructive surgery is recommended as the therapy of choice.     

胃肠癌术后复发的外科治疗

胃肠道恶性肿瘤临床主要以胃癌和结直肠癌为主。对于胃癌和肠癌患者来说，影响其预后的主要因素就是肿瘤复发问题。胃癌和结直肠癌同属消化道肿瘤，但术后癌复发的形式却明显不同。胃癌腹膜转移占40％～50％，肝转移占10％～15％；而结直肠癌则相反，肝转移占50％左右；两者预后也不一样，胃癌肝转移预后较差，结直肠癌的肝转移则发展较慢。因此，我们将两者分别加以讨论。     

Simultaneous chemoradiotherapy as salvage treatment in locoregional recurrences of squamous head and neck cancer

This study was designed to determine if long-term palliation could be obtained in pre-irradiated locoregional recurrent squamous head and neck cancer patients, with the administration of simultaneous chemoradiotherapy. Mandatory eligibility criteria were histologically documented squamous head and neck cancer in previously irradiated territory, surgical or brachytherapy salvage unfeasibility, or patient refusal. The protocol consisted of radiotherapy, at a rate of 5 daily fractions of 2 Gy on altermate weeks, with simultaneous continuous intravenous infusion of 5-fluorouracil (5FU) at 800 mg/m² and oral hydroxyurea (HU) at 1.000–1,500 mg/day for 5 days. Tolerance was good. Acute toxicity was low with no grade -? III WHO hematologic toxicity observed. Nine patients had grade III mucositis, one had grade IV, three had grade III skin toxicity, and only four patients required a 20% to 30% 5FU dose reduction because of it. Two patients had hand and foot syndrome, and two had asymptomatic 5FU-related cardiac signs (1 ECG, 1 echographic + ECG). Chronic radiotherapy-related effects consisted of Her mitte's sign observed in two patients. Of 34 registered patients, 33 were evaluable for response. An overall rate of 55% (18 patients) of objective responses [complete response (CR) + partial response (PR)] was obtained, with 12 patients (36%) achieving local control of disease. The median survival was 11 months. These data show that palliation could be obtained for the majority of responding patients, and also suggest an improvement in the immediate prognosis with this type of salvage procedure for a selected group of recurrent squamous head and neck cancer patients.     

Surgical strategies for differentiated carcinoma of the thyroid isthmus

The postoperative outcome (including clinicopathologic features) in 19 patients with differentiated thyroid cancer of the isthmus was investigated to develop more appropriate surgical strategies for these lesions. The extent of thyroidectomy, including neck dissection, tumor size, nodal involvement, and other clinical features were evaluated. The incidence of intraglandular dissemination was about 16% in all patients. Analysis of regional node metastatic distribution revealed no definite metastatic pattern. In addition, there was no apparent correlation between tumor size and nodal involvement. Two of the six patients who underwent total thyroidectomy suffered permanent postoperative hypoparathyroidism. It is thus recommended that isthmusectomy, including an adequate edge of surrounding normal thyroid tissues of each lobe and modified or limited neck dissection when cervical nodes are palpably enlarged is sufficient as an appropriate primary surgical procedure for differentiated carcinoma of the thyroid isthmus.     

Management of locoregional recurrent oropharyngeal carcinoma

Sixty-seven patients with recurrent locoregional squamous cell epithelioma of the oropharynx were reviewed to determine the curative potential of secondary therapy for recurrent carcinoma. Of the 37 patients in whom recurrent carcinoma developed after radical surgery, only 11 percent (4 of 37) had a 2 year disease-free survival following secondary treatment. Recurrence developed in 30 patients after radiation therapy. Surgical resection of the recurrent carcinoma was possible in 13 of the patients, 38 percent (5 of 13) of whom were free of disease for a minimum of 2 years. Though treatment results in patients with recurrent oropharyngeal carcinoma are discouraging, secondary therapy in selected patients can yield 2 year disease survival in over a third of cases. Favorable prognostic factors included the development of recurrent carcinoma following radiation therapy and a tumor initially classified as stage I or II, irrespective of the initial mode of therapy.     

胃肠道恶性肿瘤合并活动性肺结核的处理策略

目的探讨胃肠道恶性肿瘤合并活动性肺结核患者的处理策略。方法回顾性分析9例合并活动性肺结核胃肠道恶性肿瘤患者诊治资料。结果术前给予2周乙氨丁醇、异烟肼、利福平及吡嗪酰胺(EIRP)或异烟肼、利福平及吡嗪酰胺(IRP)强化联合抗结核病治疗后,所有患者均接受根治性肿瘤切除术,术后静脉给予异烟肼或二线抗结核药,患者可以口服时继用术前抗结核强化方案。术后2例并发肺炎,无结核播散恶化或死亡病例。7例术后强化治疗2个月痰菌转阴后改为异烟肼及利福平(IR)巩固治疗。在抗结核治疗巩固期同时行FOLFOX4或CapeOX方案化疗8疗程,无结核恶化病例。结论胃肠道恶性肿瘤合并活动性肺结核术前给予强化抗结核治疗2周后可行手术。术后可静脉给予抗结核药物。患者可以口服后可继用术前抗结核强化治疗。于抗结核巩固期开始肿瘤化疗安全可行。     

Surgical strategies in esophageal carcinoma with emphasis on radical lymphadenectomy.

From 1975 through 1988, 257 patients with carcinoma of the thoracic esophagus have been treated in our department. Operability was 90% (232/257); overall resectability, 77% (198/257), and for the operated group, 85% (198/232). Hospital mortality rate was 9.6% but decreased to 3% over the period 1986 to 1988. There were 65% squamous cell epitheliomas and 35% adenocarcinomas. Tumor, nodes, and metastases (pTNM) staging was as follows: stage I, 11.6%; stage II, 23.2%; stage III, 37.9%; stage IV, 27.3%. Overall survival rate was 62.5% at 1 year, 42.4% at 2 years, and 30% at 5 years. According to the pTNM staging, 5-year survival was 90% for stage I, 56% for stage II, 15.3% for stage III, and 0 for stage IV. There were no statistically significant differences according to tumor localization, pathologic type, sex, or age. Introducing extensive resection and extended lymphadenectomy seems to improve significantly survival in patients in whom an operation with curative intention was performed, the 1 year survival rate being 90.8% versus 72%; 2-year survival, 81% versus 46%; and 5-year survival, 48.5% versus 41% for radical and nonradical resections, respectively. Based on multivariate Cox regression analysis, only TNM stage and presence or absence of lymph nodes are important factors in predicting survival: stage 1 tumors have lower risk, and involvement of lymph nodes creates higher risk. Using this analysis, there was only for the patients with involved lymph nodes (N1) a significantly better prognosis when a radical lymph node dissection was performed (p = 0.0055). Barrett adenocarcinomas have no worse prognosis than other esophageal carcinomas, with a 5-year survival rate of 91.5% if lymph nodes are negative, and a 54% overall 5-year survival rate. Functional results after restoration of continuity with gastric tubulation were judged excellent to very good in 86.5% at 1 year, but infra-aortic anastomoses have a much higher incidence of peptic esophagitis: 53% versus 8% for cervical anastomoses. From this study it can be concluded that in experienced hands surgery today offers the best chances for optimal staging, potential cure, and prolonged high-quality palliation.     

胃肠道来源卵巢转移瘤的手术治疗及预后

目的 探讨胃肠道卵巢转移瘤的治疗方法及预后因素.方法 回顾性分析110例胃肠道卵巢转移瘤患者的治疗、生存情况及预后因素.结果 全组患者中位年龄45岁.原发病灶位于胃82例,结直肠28例.全组中位总体生存期16.3个月,中位无进展生存期8.2个月,1、3、5年的生存率分别为68.4%、15.4%和2.5%.单因素分析结果显示,原发灶部位(P＜0.01)、转移灶范围(P＜0.01)、肿瘤细胞减灭术(P＜0.01)、腹腔化疗(P＜0.05)和卵巢转移瘤组织学类型(P＜0.05)是影响患者预后的主要因素,而年龄、月经史、腹水、不同疗程化疗与患者的预后无明显相关性(P＞0.05);多因素分析结果显示,原发灶部位(P＜0.01)、转移灶范围(P＜0.05)、肿瘤细胞减灭术(P＜0.01)是影响卵巢转移瘤患者预后的独立因素.结论 卵巢转移瘤的预后较差.在切除原发肿瘤的同时,积极行满意的肿瘤细胞减灭术有助于延长患者的生存时间.     

Surgical treatment of stomal recurrences in cancer of the larynx

A study of 124 cases of cancer of the larynx treated by surgery in a general hospital revealed nine cases of stomal recurrence, that is, a recurrence at the junction of the amputated trachea and skin. Our studies suggest that the following factors may play a role in the development of this problem: preliminary tracheostomy or laryngofissure or the use of the endotracheal tube and possible tumor implantation, and inadequate initial surgery for large tumors of the vocal cords or subglottic lesions. Laryngectomy and routine radical neck dissection should be employed. If laryngectomy alone is performed, the hemithyroid should be removed on the side of the lesion in cases of small lesions. Our studies also suggest that there is a possible multicentricity of the primary lesion as indicated by the high incidence of larynx and lung cancers occurring as multiple primary lesions, and that similar etiologic factors may play a role in reducing the host resistance and allowing the stomal recurrence to develop.     

Endosonographic examination of gastrointestinal anastomoses with suspected locoregional tumor recurrence

Background: Endoscopic ultrasound is considered one of the best tools for the preoperative staging of esophageal, gastric, and rectal carcinoma. Depending on the individual investigator, the sensitivity of preoperative tumor staging by endosonography of the upper gastrointestinal tract (GEUS) is 80–92% for gastric carcinoma and 86–95% for esophageal carcinoma. However, the sensitivity and specificity of endosonography for the staging of lymph node metastases is less accurate. The accuracy of rectal endosonography (REUS) is ∼90% for tumor assessment and ∼80% for the detection of lymph node metastases. In this study, we address the question of whether endosonography enables the surgeon to distinguish scar tissue, which is rather homogeneous and echo-rich, from changes such as an anastomositis or a locoregional tumor recurrence, which are typically noninhomogeneous and echo-poor. Methods: During a 24-months period, we studied patients enrolled in a special tumor follow-up care program by either upper gastrointestinal (GEUS, n= 37 patients) or rectal endosonography (REUS, n= 49 patients) for exclusion of a locoregional tumor recurrence. In each patient, local tumor recurrence was suspected because of either medical history, clinical examination, or other diagnostic procedures. Results: As in previous studies, our retrospective analysis revealed that endosonography has a high sensitivity in the detection of local tumor recurrences (>90%) for both GEUS and REUS. Conclusion: Endosonography is a highly accurate means of detecting local tumor recurrence. Received: 9 March 1998/Accepted: 9 November 1998     

提高胃肠道肿瘤临床分期诊断正确率的意义及对策

在制定胃肠道肿瘤的手术方案和治疗计划时,准确评估肿瘤的浸润深度、淋巴结转移和远处转移情况至关重要。若低估肿瘤的临床分期可能导致切缘癌残留,或因术前漏诊远处转移而进行不必要的探查手术,而过分高估临床分期则会使原本可能根治切除的病例错误地接受姑息治疗而丧失治愈机会。NCCN指南推荐使用多种检查手段进行胃癌和结直肠癌的术前评估,如腹盆腔CT和胸部CT,内镜超声,经直肠超声,MRI,PET-CT等。由于单独采用任何一种影像检查均有技术局限性,故推荐综合应用多种检查手段以提高术前分期的准确性。