Repeat hepatectomy for colorectal liver metastases: A worthwhile operation?

BACKGROUND AND OBJECTIVES: After curative resection of hepatic colorectal metastases, 10-20% of patients experience a resectable hepatic recurrence. We wanted to assess the expected risk-to-benefit ratio in comparison to first hepatectomy and to determine the prognostic factors associated with survival. METHODS: Twenty-nine patients from a group of 152 patients resected for colorectal liver metastases underwent 32 repeat hepatectomies. RESULTS: In-hospital mortality was 3.5% (1/29 patients); the morbidity after repeat hepatectomy was lower than that after first hepatic resection. Combined extrahepatic surgery was performed on 34.5% of repeat hepatectomies vs. 6.9% of first hepatectomies (P = 0.01). Overall actuarial 3-year survival was 35.1%: four patients have survived more than 3 years and one survived for more than 5 years. The number of hepatic metastases and the carcinoembryonic antigen (CEA) serum levels were significant prognostic factors on univariate analysis. The synchronous resection of hepatic and extrahepatic disease was not associated with a lower survival rate when compared with that of patients without extrahepatic localization: three patients of the former group are alive and disease-free at more than 2 years. CONCLUSIONS: Repeat hepatic resection can provide long-term survival rates similar to those of first liver resection, with comparable mortality and morbidity. The presence of resectable extrahepatic disease must not be an absolute contraindication to synchronous hepatectomy because long-term survival is possible.     

Second-look surgery for recurrent colorectal carcinoma: is it worthwhile?

Second-look surgery for recurrent colorectal carcinoma has been advocated for over four decades. Routine follow-up procedures gave way to clinically directed or carcinoembryonic (CEA)-directed procedures in the mid-1970's. In this paper, we review the results of second-look surgery for recurrent colorectal carcinoma and ask the question, "Is it worthwhile?" Excluding surgery for symptomatic patients, we conclude that second-look surgery should only be performed for recurrent colorectal carcinoma with the intent of rendering the patient disease-free. Without effective systemic therapy, "palliative" or "debulking" procedures probably do not increase survival. The most likely candidates for such a curative approach with second-look surgery are those with isolated liver, pulmonary, and, less frequently, regional recurrences.     

Incidental gallbladder cancer: what management?

Gallbladder cancer (GBC) represents 3.8% of all gastrointestinal cancers and usually known to be of a poor prognosis. In 0.2–2.9% of cases, this cancer is found in cholecystectomy specimens. A better understanding of spread mode of this tumor helps a better surgical management. The aim of the present review is to underline the management of GBC based on the comprehension of risk factors and anatomic features. A Medline, PubMed database search was performed to identify articles published from 2000 to 2011 using the keywords ‘carcinoma of gallbladder’, ‘incidental gallbladder cancer’, ‘gallbladder neoplasm’ and ‘cholecystectomy’. Some pathological situations such as chronic lithiasis and biliopancreatic junction abnormalities have been clearly identified as predisposing to GBC. Laparoscopy increases peritoneal and parietal tumor dissemination, thus, it should not be performed when GBC is suspected. Most determinant prognostic factors are nodal, perineural and venous involvement, invasion of the cystic duct and the tumor differentiation. The simple cholecystectomy is sufficient for tumors classified as T1a; for other cancers exceeding the muscularis, radical re-resection is required due to the high risk of recurrence. This aggressive surgery improved the overall survival of patients. There is still no standard adjuvant treatment; patients should be included in prospective trials.     

Cytoreductive surgery for advanced ovarian cancer: quo vadis?

Two-thirds of women who are newly diagnosed with invasive epithelial ovarian cancer present with stage III or IV disease.The preferred initial treatment has traditionally consisted of primary surgical debulking followed by platinum-based chemotherapy. However, recent data suggesting comparable efficacy for neoadjuvant chemotherapy and interval debulking have challenged this conventional dogma. Most patients with advanced ovarian cancer will achieve remission regardless of initial treatment, but 80% to 90% of patients will ultimately relapse. The timing and clinical benefit of a second debulking operation for recurrent disease is even more contentious. This article focuses on the recent debate regarding when--or whether--patients with ovarian cancer should undergo aggressive surgical resection.     

Multimodality therapy in inflammatory breast cancer: Is there a place for surgery?

Background:In many centres surgery is used as part of a combinedmodality approach to the treatment of inflammatory breast cancer (IBC).Nevertheless, its value is controversial given the high risk of metastaticrelapse and poor overall prognosis. We have reviewed patients with true IBCprospectively treated at the Royal Marsden Hospital in chemotherapy trials toassess further the role of surgery as part of combined modality treatment. Patients and methods:Fifty-four patients who had responsive orstable disease to primary chemotherapy went on to have either radiotherapyalone (n = 35) or surgery plus radiotherapy (n = 19); thedecision on surgery was based partly on clinician preference and partly onclinical response. Results:The 35 patients undergoing radiotherapy alone had amedian progression-free survival (PFS) of 16 months and median overallsurvival (OS) of 35 months. Twenty-four patients (69%) have relapsedwith a total of twelve (34%) relapsing locally. In comparison, the 19patients receiving both surgery and radiotherapy had a PFS of 20 months, anda median OS of 35 months. Fifteen patients (79%) have relapsed, eight(42%) of these locally. None of these differences were statisticallysignificant. Conclusions:These results do not suggest a clinical advantage forsurgery in addition to chemotherapy and radiotherapy for patients with IBC.They support the need for a prospective randomised trial to address thisquestion.     

Examining the co-occurrence of bladder and prostate cancer: a worthwhile investigation?

We investigate the possible reasons for the co-occurrence of bladder and prostate cancer and discuss its clinical relevance. The co-occurrence of bladder and prostate cancer can (partly) be explained by a survival effect and diagnostic bias. Radiotherapy for prostate cancer might be responsible for a significant increase in secondary bladder cancers, with an absolute effect that is small. Existing international consortia should expand to include secondary primary cancers as well as the index tumor. This will facilitate the investigation of common etiology and will help to identify subgroups that are susceptible to treatment-induced carcinogenesis. The prognosis after a diagnosis of both bladder and prostate cancer seems to depend mainly on the prognosis of the bladder tumor.     

Patients' preferences for adjuvant chemotherapy in early-stage breast cancer: is treatment worthwhile?

When making decisions about adjuvant chemotherapy for early-stage breast cancer, costs and benefits of treatment should be carefully weighed. In this process, patients' preferences are of major importance. The objectives of the present study were: (1) to determine the minimum benefits that patients need to find chemotherapy acceptable, and (2) to explore potential preference determinants, namely: positive experience of the treatment, reconciliation with the treatment decision, and demographic variables. Preferences were elicited from patients scheduled for adjuvant chemotherapy (chemotherapy group: n = 38) before (T(1)), during (T(2)), and 1 month after chemotherapy (T(3)), and were compared to responses from patients not scheduled for chemotherapy (no-chemotherapy group: n = 38). The patients were asked, for a hypothetical situation, to indicate the minimum benefit (in terms of improved 5-year disease-free survival) to find adjuvant chemotherapy acceptable. In the chemotherapy group, the median benefit was 1% at all 3 measurement points. In the no-chemotherapy group the attitude towards chemotherapy became more negative over time, although not statistically significantly so (T(1): 12%, T(2): 15%, T(3): 15%; P = 0.10). At all measurement points, the patients in the chemotherapy group indicated that they would accept chemotherapy for significantly (P< 0.01) less benefit than the patients in the no-chemotherapy group. Of the demographic variables, age was related to preferences, but only at T(2)and only in the no-chemotherapy group. The more positive attitude towards chemotherapy and the stability of preferences in the chemotherapy group indicated that reconciliation with the treatment decision was a more important determinant of patients' preferences than positive experience of the treatment.