Oncologic Outcomes After Radical Surgery Following Preoperative Chemoradiotherapy for Locally Advanced Lower Rectal Cancer: Abdominoperineal Resection Versus Sphincter-Preserving Procedure

Background  Over the past several years, preoperative chemoradiotherapy (CRT) has contributed remarkably to make more sphincter-preserving procedure (SPP) possible for lower rectal cancer. The aim of this study was to compare the outcomes between abdominoperineal resection (APR) and SPP after preoperative CRT in patients with locally advanced lower rectal cancer. Methods  A retrospective investigation was conducted with a total of 122 patients who underwent radical surgery combined with preoperative CRT for locally advanced lower rectal cancer. Of these, 50 patients underwent APR and 72 received SPP. Surgery was performed 6–8 weeks after completion of preoperative CRT. Oncologic outcomes were compared between the two groups, and the clinicopathologic factors affecting the treatment outcomes were evaluated. Results  Circumferential resection margin (CRM) involvement (P = 0.037) and postoperative complication rate (P = 0.032) were significantly different between APR and SPP. Patients who underwent APR had a higher 5-year local recurrence (22.0% vs. 11.5%, P = 0.028) and lower 5-year cancer-specific survival (52.9% vs. 71.1%, P = 0.03) rate than those who underwent SPP. Pathologic N stage was the most critical predictor for local recurrence and survival. Conclusions  Our study shows that APR following preoperative CRT exhibited more adverse oncologic outcomes compared with SPP. This result may be due to higher rates of CRM involvement in APR even with preoperative CRT. We suggest that sharp perineal dissection and wider cylindrical excision at the level of the anorectal junction are required to avoid CRM involvement and improve oncologic outcomes in patients who undergo APR following preoperative CRT.     

Anastomotic Leakage is Associated with Poor Long-Term Outcome in Patients After Curative Colorectal Resection for Malignancy

The impact of anastomotic leakage on long-term outcomes after curative surgery for colorectal cancer has not been well documented. This study aimed to investigate the effect of anastomotic leakage on survival and tumor recurrence in patients who underwent curative resection for colorectal cancer. Prospectively collected data of the 1,580 patients (904 men) of a median age of 70 years (range: 24–94), who underwent potentially curative resection for colorectal cancer between 1996 and 2004, were reviewed. Cancer-specific survival and disease recurrence were analyzed using Kaplan Meier method, and variables were compared with log rank test. Cox regression model was used in multivariate analysis. The cancer was situated in the colon and the rectum in 933 and 647 patients, respectively. Anastomotic leakage occurred in 60 patients (clinical leakage: n = 48; radiological leak: n = 12). The leakage rate was significantly higher in patients with surgery for rectal cancer (6.3 vs 2.0%, p < 0.001). The 5-year cancer-specific survivals were 56.9% in those with leakage and 75.9% in those without leakage (p = 0.012). The 5-year systemic recurrence rates were 48.4 and 22.6% in patients with and without anastomotic leak, respectively (p = 0.001), whereas the 5-year local recurrence rates were 12.9 and 5.7%, respectively (p = 0.009). Anastomotic leakage remained an independent factor associated with a worse cancer-specific survival (p = 0.043, hazard ratio: 1.63, 95% CI: 1.02–2.60) and a higher systemic recurrence rate (hazard ratio: 1.94, 95% CI: 1.23–3.06, p = 0.004) on multivariate analysis. In rectal cancer, anastomotic leakage was an independent factor for a higher local recurrence rate (hazard ratio: 2.55, 95% CI: 1.07–6.06, p = 0.034). In conclusion, anastomotic leakage is associated with a poor survival and a higher tumor recurrence rate after curative resection of colorectal cancer. Efforts should be undertaken to avoid this complication to improve the long-term outcome. This work was presented in the plenary session of the 47th Annual Meeting of the Society for Surgery of the Alimentary Tract at the Digestive Disease Week in Los Angeles on 22 May 2006.     

Laparoscopic total mesorectal excision (TME) for rectal cancer surgery: long-term outcomes

Background: Total mesorectal excision (TME) offers the lowest reported rates of local recurrence and the best survival results in patients with rectal cancer. However, the laparoscopic approach to resection for colorectal cancer remains controversial due to fears that oncologic principles will be compromised. We assessed the feasibility, safety and long-term outcome of laparoscopic rectal cancer resections following the principles of TME. The aim of this study was to evaluate the perioperative outcome and long-term results of laparoscopic TME. Methods: We reviewed the prospective database of 102 consecutive unselected patients undergoing laparoscopic TME for rectal cancer between November 1991 and December 2000. Follow-up was done through office charts or direct patient contact. Recurrence and survival curves were generated by the Kaplan-Meier method. Results: Laparoscopic TME was completed successfully in 99 patients, whereas conversion to an open approach was required in three cases (3%). The overall morbidity and mortality rates were 27% and 2%, respectively, with an overall anastomotic leak rate of 17%. Of the 102 patients, four were excluded from the oncologic evaluation because final pathology was not confirmatory (two had anal canal squamous cell carcinoma and two had villous adenoma with dysplasia). In 90 of the 98 remaining patients (91.8%), the resection was considered curative. The remainder had a palliative resection due to synchronous metastatic disease or locally advanced disease. Mean follow-up was 36 months (range, 6–96). There were no trocar site recurrences. The local recurrence rate was 6%, and the cancer-specific survival of all curatively resected patients was 75% at 5 years. The overall survival rate of all curatively resected patients was 65% at 5 years; mean survival time was 6.23 years (95% confidence interval [CI], 5.39–7.07). Conclusion: Laparoscopic TME is feasible and safe. The laparoscopic approach to the surgical treatment of operable rectal cancer does not seem to entail any oncologic disadvantages. Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), New York, NY, USA, 13–16 March 2002     

Surgical Outcomes of Patients with Gastrointestinal Stromal Tumors in the Era of Targeted Drug Therapy

Background  The discovery of the c-KIT mutation and the advent of targeted drug therapy with imatinib mesylate have revolutionized the management of gastrointestinal stromal tumors (GISTs). The outcome of patients with surgically treated GISTs treated in the era of targeted drug therapy was assessed and factors associated with adverse outcomes determined. Materials and Methods  Patients with GISTs requiring surgery at a tertiary care center from 2002 to 2007 were reviewed and prognostic factors determined. Results  Forty patients were surgically treated for GISTs. The median age at presentation was 59 years. The stomach (55%) was the main site of primary disease. The median tumor size was 7 cm. Eleven (28%) patients had metastatic disease at presentation. Surgery was undertaken in all patients with curative intent. Multi-organ resection was required in 10 (25%) patients. Imatinib mesylate was administered postoperatively in 68% of cases. Median follow-up was 24 months. There was a 40% recurrence rate with 63% undergoing repeat surgical resection. The peritoneum and liver were the main sites of recurrent disease. The 5-year disease-specific survival and disease-free survival (DFS) were 65% and 35%, respectively. High mitotic rate (P = 0.017) and tumor size greater than 10 cm (P = 0.009) were the only prognostically significant adverse factors of DFS on multivariate analysis, independent of imatinib mesylate treatment. Conclusion  Aggressive surgical treatment and follow-up of GISTs, combined with targeted drug therapy, leads to long-term DFS survival. Tumor recurrence is independently associated with a high tumor mitotic rate and size greater than 10 cm, despite the use of adjuvant targeted drug therapy.     

MFH revisited: outcome after surgical treatment of undifferentiated pleomorphic or not otherwise specified (NOS) sarcomas of the extremities—an analysis of 140 patients

Background  Undifferentiated pleomorphic sarcoma/NOS (not otherwise specified; former pleomorphic and storiform MFH) of the extremities is a common malignant soft tissue tumor in adults. The objective of this study is to determine prognostic factors for the outcome after surgical treatment with respect to the recent developments in classification. Methods  From 1996 to 2004, 140 undifferentiated pleomorphic sarcomas/NOS were identified out of 1,200 soft tissue sarcomas of the extremities that were treated at our institution and recorded in a prospective database. Overall survival (OS) and isolated local recurrence (ILR) were determined by Kaplan–Meier analysis. All tumors were retrospectively analyzed regarding prognostic factors of the disease, including patient’s background (primary or recurrent), histological grade (G2/G3), adjuvant chemotherapy and radiotherapy, size (T1–2) and depth of the tumor, and surgical margins (R0, R1, R2). Results  In 123 patients, a wide resection was performed (limb-sparing surgery). In nine patients, an amputation was necessary. The overall 5-year survival rate was 72% (median follow up: 52 months). There was a significant difference between the group presenting with primary tumors (5-year survival: 84%, p < 0.05) and recurrent tumors (5-year survival: 62%, p < 0.05). Isolated local recurrence occurred in 36 patients. Conclusions  In terms of OS and ILR, primary or recurrence, negative surgical margins, size and grading had a highly significant influence, whereas the site of surgery and adjuvant chemotherapy, adjuvant radiation and tumor depth did not. Prognosis for patients with undifferentiated pleomorphic sarcoma of the extremities depends predominantly on adequate wide resection of the primary tumor. Marcus Lehnhardt and Adrien Daigeler contributed equally to the study.     

Operative Safety and Oncologic Outcomes of Anal Sphincter-Preserving Surgery with Mesorectal Excision for Rectal Cancer: 931 Consecutive Patients Treated at a Single Institution

Background  This study was designed to evaluate the operative safety and long-term oncologic outcomes of sphincter-preserving surgery based on sharp mesorectal excision for rectal cancer. Methods  Between January 1989 and June 2004, 931 patients underwent sphincter-preserving surgery based on sharp mesorectal excision. The operative safety and oncologic outcomes were assessed for the periods of 1989–1996 (n = 208) and 1997–2004 (n = 723). Total mesorectal excision (TME)-based sphincter-preserving surgery was performed during the period of 1989–1996. A multidisciplinary team approach and tailored mesorectal excision, which is the differential removal of the mesorectum, were our standard treatment for patients with rectal cancer during the period of 1997–2004. Results  The use of preoperative chemoradiation (P < 0.001), ultralow anterior resection with coloanal anastomosis (P = 0.01), diverting stoma (P = 0.001), and <2 cm of a distal resection margin (P = 0.01) were more common during the period of 1997–2004. There were no differences between the two periods with regard to perioperative complications (P = 0.2), such as anastomosis leakage (2.4% vs. 3.6%). Cancer-specific survival rates (79.1% vs. 79.6%, P = 0.7) and local recurrence (8.4% vs. 8.6%, P = 0.99) did not differ significantly for the two periods. Conclusions  Based on sharp mesorectal excision, operative safety and oncologic outcomes were not compromised by technical advances in sphincter-preserving surgery using tailored mesorectal excision and a shortened distal margin.     

Comparison of Outcome of Open and Laparoscopic Resection for Stage II and Stage III Rectal Cancer

Background  Laparoscopic resection for advanced rectal cancer has not been widely accepted, and there are only few studies with survival data. This study aimed to compare the survival of patients who underwent laparoscopic and open resection for stage II and III rectal cancer. Materials and Methods  Consecutive patients (open resection: n = 310; laparoscopic resection: n = 111) who underwent curative resection for stage II and III rectal cancer from June 2000 to December 2006 were included. The operative details, postoperative complications, postoperative outcomes, and survival data were collected prospectively. Comparison was made between patients who had laparoscopic and open surgery. Results  The age, gender, medical morbidity, types of operation, and American Society of Anesthesiologists (ASA) status were similar between the two groups. There was also no difference in the mortality, morbidity, and pathological staging. Laparoscopic resection was associated with significantly less blood loss and shorter hospital stay. With the median follow-up of 34 months, there was no difference in local recurrence rates. The 5-year actuarial survivals were 71.1% and 59.3% in the laparoscopic and open groups, respectively (P = .029). In the multivariate analysis, laparoscopic resection was one of the independent significant factors associated with better survival (P = .03, hazards ratio: 0.558, 95% confidence interval: 0.339–0.969). Other independent poor prognostic factors included lymph node metastasis, poor differentiation, perineural invasion, presence of postoperative complications, and no chemotherapy. Conclusions  Laparoscopic resection for locally advanced rectal cancer is associated with more favorable overall survival when compared with open resection.     

Liver metastasis as an initial recurrence has no impact on the survival of patients with resectable pancreatic adenocarcinoma

Background  Prognosis of the patients with pancreatic adenocarcinoma is still poor due to a recurrence, and liver metastasis is a distant metastasis that is foreboded the short survival period. Methods  Between 1999 and 2005, 68 patients for pancreatic adenocarcinoma underwent a pancreaticoduodenectomy (n = 17), a pylorus-preserving pancreaticoduodenectomy (n = 27), distal pancreatectomy (n = 22), or total pancreatectomy (n = 2) with an extensive lymph node dissection. Results  A tumor recurrence occurred to 55 patients (13 of the liver, 21 of the local recurrence, 16 of peritoneal dissemination, three of the lymph node, and two of lung). The low tumor grade and female demonstrated a risk factor for a liver metastasis (P = 0.043, P = 0.031). A logistic regression analysis demonstrated female (P = 0.02) and low tumor grade (P = 0.04) as independent risk factors for recurrence with liver metastasis. The median survival time (MST) was 13.6 months, and MST of patients with a liver metastasis as an initial recurrent site was 13.7 months; the liver metastasis as an initial recurrent site has no impact on the MST after pancreatic resection. Conclusions  We concluded potentially supporting the hypothesis that even patients thought to be at higher risk of liver metastasis may still be given the chance of resection, considering the satisfying survival.     

Patterns of pelvic invasion are prognostic in the treatment of locally recurrent rectal cancer.

BACKGROUND: Local recurrence of rectal cancer after curative resection remains a difficult clinical problem. The aim of this study was to elucidate prognostic risk factors after resection of recurrent cancer. METHODS: Between January 1983 and December 1999, 83 patients with locally recurrent rectal cancer were studied retrospectively for survival benefit by re-resection. Sixty patients underwent resection for recurrent cancer, including total pelvic exenteration in 30 patients and sacrectomy in 23 patients. The extent of locally recurrent tumour was classified by the pattern of pelvic invasion as follows: localized, sacral invasion and lateral invasion. RESULTS: Multivariate analysis showed that the pattern of pelvic invasion was a significant prognostic factor which independently influenced survival after resection of recurrent cancer (P < 0.001). The 5-year survival rates were 38 per cent in the localized type (n = 27), 10 per cent in the sacral invasive type (n = 16) and zero in the lateral invasive type (n = 17). CONCLUSION: Resection for locally recurrent rectal cancer is potentially curative in patients with localized or sacral invasive patterns of recurrence. Alternatives should be explored in patients with recurrence involving the lateral pelvic wall.     

Sphincter-Preserving Operations Following Preoperative Chemoradiation: An Alternative to Abdominoperineal Resection for Lower Rectal Cancer?

BACKGROUND: Sphincter-preserving operations (SPO) for lower rectal cancer are on the rise. In the study reported here, we compared the oncologic outcomes of patients who underwent sphincter-preserving operations following preoperative chemoradiation for lower rectal cancer with the outcome for patients who underwent abdominoperineal resection (APR). METHODS: This prospective study included 87 patients who underwent proctectomy with curative intent for locally advanced rectal cancer that was located less than 6 cm from the anal verge. Forty-four patients had APR with no preoperative treatment. Forty-three patients underwent concurrent chemoradiation therapy (CCRT) consisting of preoperative 5-fluorouracil-based chemotherapy and pelvic radiation (4500-5040 cGy); this was followed 6 weeks later by surgery (SPO/CCRT). The oncologic outcomes between the two groups were compared, and factors affecting survival were evaluated. RESULTS: The median follow-up period was 56.2 months. The overall postoperative complication rates did not significantly differ between SPO/CCRT and APR (32.6% versus 34.2%; p = 0.879). Also, there were no significant differences in the overall recurrence rate (20.9% versus 20.5%; p = 0.956) and 5-year overall survival rate (70.8% versus 62.9%; p = 0.189) between the two groups. By multivariate analysis, only the pathologic N stage was significantly associated with overall survival (p < 0.001). CONCLUSIONS: Sphincter-preserving operation with CCRT could be another option for the treatment of locally advanced lower rectal cancer in patients who are clinically considered for APR, with no deterioration of oncologic outcomes. For patients undergoing curative resection for lower rectal cancer, the pathologic N stage can provide valuable prognostic information about survival.     

Analysis of Recurrence Pattern and Its Influence on Survival Outcome After Radiofrequency Ablation of Hepatocellular Carcinoma

Background Radiofrequency ablation (RFA) is an effective local ablation therapy for hepatocellular carcinoma (HCC) with favorable long-term outcome. There is no data on the analysis of recurrence pattern and its influence on long-term survival outcome after RFA in HCC patients. Aim of Study To evaluate the tumor recurrence pattern and its influence on long-term survival in patients with HCC treated with RFA. Patients and Methods From April 2001 to January 2005, 209 patients received RFA using internally cooled electrode as the sole treatment modality for HCC. Among them, 117 patients (56%) had unresectable HCC because of bilobar disease, poor liver function, and/or high medical risk for resection; whereas 92 patients (44%) underwent RFA as the primary treatment for small resectable HCC. The ablation procedure was performed through percutaneous (n = 101), laparoscopic (n = 17), or open approaches (n = 91). The tumor recurrence pattern and long-term survival were analyzed. Multivariate analysis was carried out to identify independent prognostic factors affecting the overall survival of patients. Results The mortality and morbidity rates were 0.9 and 15.7%, respectively. Complete tumor ablation was achieved in 192 patients (92.7%). With a median follow-up period of 26 months, local recurrence occurred in 28 patients (14.5%). Same segment and different segment intrahepatic recurrence occurred in 30 patients (15.6%) and 78 patients (40.6%), respectively. Twenty patients (10.4%) developed distant extrahepatic metastases. The overall 1-, 3-, and 5-year survival rates were 87.2, 66.6, and 42%, respectively. Different segment intrahepatic recurrence and distant recurrence after RFA carried significant poor prognostic influence on overall survival outcome. Using multivariate analysis, Child–Pugh grade (risk ratio [RR] = 2.918, 95% confident interval [CI] 1.704–4.998, p = 0.000), tumor size (RR = 1.231, 95% CI 1.031–1.469, p = 0.021), and pattern of recurrence (risk ratio [RR] = 1.464, 95% CI 1.156–1.987, P = 0.020) were identified as independent prognostic factors for overall survival. Conclusion The tumor recurrence pattern after RFA carries significant prognostic value in relation to overall survival. Long-term regular surveillance and aggressive treatment strategy are required for patients with different segment intrahepatic recurrence to optimize the benefits of RFA.     

Abdominal Sacral Resection for Posterior Pelvic Recurrence of Rectal Carcinoma: Analyses of Prognostic Factors and Recurrence Patterns

Background Local recurrence of rectal cancer presents challenging problems. Although abdominal sacral resection (ASR) provides pain control, survival prolongation, and possibly cure, reported morbidity and mortality are still high, and survival is still low. Thus, appropriate patient selection and adjuvant therapy based on prognostic factors and recurrence patterns are necessary. The purpose of this study was to evaluate the results of ASR for posterior pelvic recurrence of rectal carcinoma and to analyze prognostic factors and recurrence patterns. Methods Forty-four patients underwent ASR for curative intent in 40 and palliative intent in 4 cases. All but one could be followed up completely. Multivariate analyses of factors influencing survival and positive surgical margins were conducted. Results Morbidity and mortality were 61% and 2%, respectively. Overall 5-year survival was 34%. The Cox regression model revealed a positive resection margin (hazard ratio, 10 [95% confidence interval, 3.8–28]), a local disease–free interval of <12 months (4.2 [1.8–9.8]), and pain radiating to the buttock or further (4.2 [1.6–11]) to be independently associated with poor survival. The logistic regression model showed that macroscopic multiple expanding or diffuse infiltrating growths were independently associated with a positive margin (7.5 [1.4–40]). Of the patients with recurrence, 56% had failures confined locally or to the lung. Conclusions ASR is beneficial to selected patients in terms of survival. To select patients, evaluation of the resection margin, the local disease–free interval, pain extent, and macroscopic growth pattern is important. To improve survival, adjuvant treatment should be aimed at local and lung recurrences. Presented at the Annual Meeting of the Society of Surgical Oncology, San Diego, California, March 23–26, 2006.     

Prognostic Significance of Circumferential Resection Margin Following Total Mesorectal Excision and Adjuvant Chemoradiotherapy in Patients with Rectal Cancer

Background This study was designed to evaluate the prognostic value of circumferential resection margin (CRM) in rectal cancer patients who underwent curative resection with adjuvant chemoradiotherapy (CRT). Methods We studied 504 patients who underwent total mesorectal excision with adjuvant CRT for rectal cancer between 1997 and 2001. The patients were divided into two groups: a negative CRM group (CRM > 1 mm) and a positive CRM group (CRM ≤ 1 mm). The survival rates, local recurrence rates, and systemic recurrence rates were compared between groups. Results The negative CRM group had 460 patients and the positive CRM group had 44 patients. The 5-year local and systemic recurrence rates were 11.3 and 25.3%, respectively, in the negative CRM group and 35.2 and 60.8% in the positive CRM group, respectively. The cancer-specific 5-year survival rates for the two groups were 72.5 and 26.9% (P < .001), respectively. CRM was found to be an independent prognostic factor by multivariate analyses which were adjusted for known outcome predictors (P < .001). Conclusion Oncological outcome for patients in the positive CRM group is less favorable than for those in the negative CRM group. Adjuvant CRT is not a definite treatment modality that can be used to compensate for a positive CRM following TME and adjuvant CRT in patients with TNM stage II or III rectal cancer.     

Radical Redo Surgery for Local Rectal Cancer Recurrence Improves Overall Survival: A Single Center Experience

Background  To date, the survival benefit of redo surgery in locally recurrent rectal adenocarcinoma remains unclear. Study Design  In an institutional study, operations for recurrence were retrospectively analyzed. Survival was calculated using the Kaplan–Meier plot and Cox regression analysis. Results  A total of 72 patients with local recurrence were explored or resected. In 38 patients, there was synchronous distant organ recurrence. Forty-five of 72 were re-resected and in 37 of 45 cases, R0 situations were achieved. In 11 of 38 metastasized patients, both local and distant organ recurrence were successfully removed. For obtaining tumor control, resections of inner genitals, bladder, and sacral bone were necessary in 10, 4, and 11 patients, respectively. Survival was better for patients re-resected with a median overall survival of 54.9 months, as compared with 31.1 months among non-resected patients (p = 0.0047, log-rank test). Subgroup analysis revealed that a benefit of re-resection was observed to a lesser extent in synchronous local and in distant disease. Cox analysis showed that initial Dukes stage and complete resections of local recurrences were independently determining prognosis (relative risk 1.762 and 0.689, p = 0.008 and p = 0.002, respectively). Conclusions  Radical surgery for local recurrence can improve survival if complete tumor clearance is achieved, and concomitant distant tumor load should not principally preclude re-resection.     

Prognosis and Results After Resection of Very Large (≥10 cm) Hepatocellular Carcinoma

Introduction Few potentially curative treatment options exist besides resection for patients with very large (≥10 cm) hepatocellular carcinoma (HCC). We sought to examine the outcomes and risk factors for recurrence after resection of ≥10 cm HCC. Methods Perioperative and long-term outcomes were examined for 189 consecutive patients from 1993 to 2004 who underwent potentially curative resection of HCC ≥10 cm (n = 24; 13%) vs. those with HCC <10 cm (n = 165; 87%). Disease-free survival (DFS) and overall survival (OS) were determined by Kaplan–Meier analysis and patient, tumor, and treatment characteristics were compared using univariate and multivariate analysis. Results Median follow-up was 34 months. Tumors ≥10 cm were more likely to be symptomatic, of poorer grade, and have vascular invasion (p < 0.05). Twelve patients (50%) underwent an extended resection of more than four hepatic segments or resection of adjacent organs for oncologic clearance (diaphragm-2, inferior vena cava (IVC)-2, median sternotomy-1). Postoperative complications were more common after resection of >10 cm HCC (12/24, 50% vs. 35/165, 21%; p = 0.04). Median DFS was significantly shorter in patients with large HCC (≥10 cm) group compared to patients with smaller HCC (8.4 vs. 38 months; p = 0.001), but overall survival was not different between the two groups (5-year survival 54% vs. 53%; p = 0.43). Seventeen patients (71%) with very large HCC developed recurrences (12 intrahepatic, five systemic); eight of these patients (47%) underwent additional therapy (resection-4, TACE-3, RFA-1). Pathological positive margins and vascular invasion were significant determinants of DFS in tumors ≥10 cm (p < 0.05), but only vascular invasion was an independent risk factor for recurrence after multivariate analysis (HR 0.17; 95% CI: 0.04–0.8). Median OS after recurrence was 24 months. Conclusion Surgical resection is the optimal therapy for very large (≥10 cm) HCC. Although recurrences are common after resection of these tumors, overall survival was not significantly different from patients after resection of smaller HCC in this series. Presented at the 2006 American Hepato-Pancreatico-Biliary Congress, Miami, FL, March 9–12, 2006.     

Prognostic Factors in Patients with Locally Advanced Rectal Adenocarcinoma Treated with Preoperative Radiotherapy and Surgery

Preoperative radiation therapy (PRT) prior to potential curative resection for rectal adenocarcinoma is not widely accepted. This report evaluates the prognostic factors affecting local recurrence and 5-year survival. This is a retrospective study of 214 patients with primary rectal adenocarcinoma treated from January 1986 to December 1994. A PRT dosage of 45 Gy in 20 fractions was administered to patients with clinically tethered or fixed tumors, and 4 to 8 weeks later surgery was performed (group I). Patients with clinically mobile tumors were treated by surgery alone (group II). There were 130 men and 84 women. The median age was 58 years (range 19–85 years). There were 111 patients in group I: 7 patients had no microscopic residual tumor, 80 had Dukes' A and B, and 24 had Dukes' C. There were 103 patients in group II: 70 patients were classified as Dukes' A and B and 33 as Dukes' C. The mean follow-up of the entire cohort was 62 months (range 2–132 months). Local recurrence was seen in 17% of patients in group I and 35% in group II (p= 0.002). Distant recurrence in patients with metastatic lymph nodes was seen in 79% of group I and in 34% of group II (p= 0.001). The favorable prognostic factors for local control were the administration of PRT and well differentiated cancer. The favorable prognostic factors for survival were age < 50 years and the absence of lymph node metastasis. The administration of PRT diminishes the risk of local recurrence. The presence of metastatic lymph nodes in the postirradiated specimen is an ominous prognostic factor for survival. Therefore such patients should be considered for adjuvant chemotherapy.     

Anterior resection for rectal cancer with mesorectal excision: a prospective evaluation of 622 patients

OBJECTIVE: This study aims to review the operative results and oncological outcomes of anterior resection for rectal and rectosigmoid cancer. Comparison was made between patients with total mesorectal excision (TME) for mid and distal cancer and partial mesorectal excision (PME) for proximal cancer, when a 4- to 5-cm mesorectal margin could be achieved. Risk factors for local recurrence and survival were also analyzed. SUMMARY BACKGROUND DATA: Anterior resection has become the preferred treatment option rectal cancer. TME with sharp dissection has been shown to be associated with a low local recurrence rate. Controversies still exist as to the need for TME in more proximal tumor. METHODS: Resection of primary rectal and rectosigmoid cancer was performed in 786 patients from August 1993 to July 2002. Of these, 622 patients (395 men and 227 women; median age, 67 years) underwent anterior resection. The technique of perimesorectal dissection was used. Patients with mid and distal rectal cancer were treated with TME while PME was performed for those with more proximal tumors. Prospective data on the postoperative results and oncological outcomes were reviewed. Risk factors for anastomotic leakage, local recurrence, and survival of the patients were analyzed with univariate and multivariate analysis. RESULTS: The median level of the tumor was 8 cm from the anal verge (range, 2.5-20 cm) and curative resection was performed in 563 patients (90.5%). TME was performed in 396 patients (63.7%). Significantly longer median operating time, more blood loss, and a longer hospital stay were found in patients with TME. The overall operative mortality and morbidity rates were 1.8% and 32.6%, respectively, and there were no significant differences between those of TME and PME. Anastomotic leak occurred in 8.1% and 1.3% of patients with TME and PME, respectively (P < 0.001). Independent factors for a higher anastomotic leakage rate were TME, the male gender, the absence of stoma, and the increased blood loss. The 5-year actuarial local recurrence rate was 9.7%. The advanced stage of the disease and the performance of coloanal anastomosis were independent factors for increased local recurrence. The 5-year cancer-specific survival was 74.5%. The independent factors for poor survival were the advanced stage of the disease and the presence of lymphovascular and perineural invasion. CONCLUSIONS: Anterior resection with mesorectal excision is a safe option and can be performed in the majority of patients with rectal cancer. The local recurrence rate was 9.7% and the cancer-specific survival was 74.5%. When the tumor requires a TME, this procedure is more complex and has a higher leakage rate than in those higher tumors where PME provides adequate mesorectal clearance. By performing TME in patients with mid and distal rectal cancer, the local control and survival of these patients are similar to those of patients with proximal cancers where adequate clearance can be achieved by PME.     

Prognosis of upper-third gastric carcinoma patients with invasion of the lower esophagus

Background and aims  Epidemiological studies show a continuing rise in the prevalence of upper-third gastric carcinoma. We compared the clinicopathologic features and prognosis in these patients, with and without lower esophageal invasion. Patients and methods  We reviewed the hospital records of 42 patients with lower esophageal invasion seen between 1986 and 2000. Results  Borrmann type IV gastric carcinoma was more frequently found in patients with esophageal invasion (P < 0.001). Multivariate analysis indicated that curability, the extent of lymph node dissection, and lymph node metastases were significant prognostic factors. When the patients with esophageal invasion were divided into those with or without curative resection, the 5-year survival rates were 37.3% and 0%, respectively (P < 0.001). In patients with lymph node dissection above the D2 lymph node, the 5-year survival rate was higher than that of patients with dissection below the D2 node level (34.4% vs 0%, P < 0.001). Conclusion  According to our results, curative resection and extensive lymph node dissection were the determining factors in improving survival.     

Laparoscopic rectal resection with anal sphincter preservation for rectal cancer

Background Total mesorectal excision (TME) is the surgical gold standard treatment for middle and low third rectal carcinoma. Laparoscopy has gradually become accepted for the treatment of colorectal malignancy after a long period of questions regarding its safety. The purposes of this study were to examine prospectively our experience with laparoscopic TME and high rectal resections, to evaluate the surgical outcomes and oncologic adequacy, and to discuss the role of this procedure in the treatment of rectal cancer. Methods Between December 1992 and December 2004, all patients who underwent elective laparoscopic sphincter preserving rectal resection for rectal cancer were enrolled prospectively in this study. Data collection included preoperative, operative, postoperative and oncologic results with long-term follow-up. Results A total of 218 patients were operated on during the study period: 142 patients underwent laparoscopic TME and 76 patients underwent anterior resection. Of the TME patients, 122 patients were operated using the double-stapling technique, and 20 patients underwent colo-anal anastomosis with hand-sewn sutures. Mean operative time was 138 min (range, 107–205), and mean blood loss was 120 ml (range, 30–350). Conversion to open surgery occurred in 26 cases (12%). Mortality rate during the first 30 days was 1%. Anastomotic leaks were observed in 10.5% of the patients. Of these, 61.9% needed reoperation and diverting stoma, and the rest were treated conservatively. Three patients had postoperative bleeding requiring relaparoscopy. Other minor complications (infection and urinary retention) occurred in 9.1% of patients. Mean ambulation time and mean hospital stay were 1.6 days (range, 1–5) and 6.4 days (range, 3–28) , respectively. Patients were followed for a mean period of 57 months. No port site metastases were observed during follow-up. The recurrence rate was 6.8 %. Overall survival rate was 67% after 5 years and 53.5% after 10 years. Conclusion Laparoscopic anterior resection and TME with anal sphincter preservation for rectal cancer is feasible and safe. The short- and long-term outcomes reported in this series are comparable with those of conventional surgery.     

Prognostic Factors and Adjuvant Chemoradiation Therapy After Pancreaticoduodenectomy for Pancreatic Adenocarcinoma

Background  The aim of this study was to determine prognostic factors for survival after resection of pancreatic adenocarcinoma (PC) and to compare outcomes after surgery alone versus surgery plus adjuvant therapy. Methods  We performed a retrospective review of 219 patients who underwent pancreaticoduodenectomy for PC with curative intent between 1995 and 2007. Data were collected prospectively. Postoperative adjuvant chemoradiation therapy (CRT) consisted of fluorouracil or gemcitabine-based chemotherapy; the median radiation dose was 45 Gy. Results  The 3- and 5-year overall survival (OS) rates were 24.3% and 14.2%, respectively. Median OS was 14.0 months [95% confidence interval (CI), 12–16 months]. Patients with metastatic lymph nodes experienced improved median survival (16 vs 10 months; P < 0.001) and 3-year OS (3-year OS 28% vs 8%) after adjuvant CRT compared with those who had no CRT. Patients who underwent non-curative resection had the same effect (median OS, 13 vs 8 months; P = 0.037). Lymph node metastasis and non-curative resection showed no significance on multivariate analysis. Poor differentiation [risk ratio (RR) = 2.10; P < 0.001] and tumor size >3 cm (RR = 1.57; P = 0.018) were found to be adverse prognostic factors; adjuvant CRT had borderline significance (RR = 0.70; P = 0.087). Conclusions  Adjuvant CRT benefited a subset of patients with resected PC, particularly those with lymph node metastasis and those undergoing non-curative resection. Multivariate analysis demonstrated that patients with tumors larger than 3 cm and poor differentiation had poor prognosis.