早期胃癌内镜下切除术后复发的相关因素分析

目的 探讨早期胃癌内镜下切除术后复发的相关性因素.方法 回顾性分析解放军总医院169例早期胃癌经内镜下切除治疗并定期随访患者的临床病理资料.结果 随访时间13～57个月(中位时间24.5个月),169例患者中12例出现胃癌复发,总复发率为7.10%,复发时间为3～36(28±23)个月,中位时间18个月,0.5、1、2、3年的复发率分别为1.18%(2/169)、3.55%(6/169)、9.91%(11/111)、12.24%(12/98).12例复发患者有11例发生在2年以内,其中组织分化不良(低分化腺癌和印戒细胞癌)、浸润至黏膜下层、有淋巴管浸润的早期胃癌容易出现术后复发(P＜0.05).结论 早期胃癌内镜下切除术后的复发多出现在2年以内.组织分化不良、肿瘤浸润至黏膜下层及有淋巴管浸润是术后复发的危险因素,严谨的内镜随访对于这些患者尤为重要.

Abstract：

Objective To investigate the related factors of recurrence of early gastric cancer (EGC) after endoscopic resection. Methods Clinicopathologic data of 169 patients with EGC who underwent endoscopic resection and periodically followed up by the Chinese PLA General hospital were analyzed retrospectively. Results During a follow-up of 13-57 months (median time 24. 5 months), 12patients had gastric cancer again and the recurrence rate was 7. 1% (12/169). The recurrence time varied from 3 to 36 (28 ± 23)months and the median time was 18 months. The recurrence rates of 0.5 year, 1st year, 2nd year and 3rd year were 1.18% (2/169), 3.55% (6/169), 9.91% (11/111) and 12.24%(12/98), respectively. Eleven patients had gastric cancer again within 2 years after resection.Undifferentiated histology (including poorly differentiated carcinoma and signet ring cell carcinoma),submucosal infiltration and lymphovascular invasion of the primary lesion of EGC were related to thepostsurgical recurrence ( all P ＜ 0. 05). Conclusion Most recurrence of EGC occurred within 2 years afterendoscopic resecton and is related with undifferentiated histology, submucosal infiltration andlymphovascular invasion. It is important for these patients to receive endoscopy follow up.     

早期胃癌内镜下非治愈性切除后胃内再发的危险因素分析

目的 探讨早期胃癌（EGC）非治愈性切除后胃内再发的危险因素。方法 收集2008年10月到2018年6月,于上海仁济医院消化内镜中心行早期胃癌内镜下治疗结果为非治愈性切除,并选择继续随访的59例患者相关资料,运用单因素Logistic回归分析胃内再发危险因素。结果 随访4~77个月,中位时长40个月,出现胃内再发11例,单因素Logistic回归分析显示淋巴脉管侵犯（OR=8.63,95%CI：1.24~60.04,P=0.030）和eCura高危分级（OR=7.31,95%CI：1.05~51.10,P=0.045）是胃内再发的危险因素。结论 非治愈性切除后可考虑常规行eCura分级评估,存在淋巴脉管侵犯或eCura分级高危者不建议继续随访;eCura分级低危者可继续行内镜随访,并注意观察原病灶周围是否存在异常。     

Peritoneal recurrence of gastric adenocarcinoma after curative resection

BACKGROUND/AIMS: Death from gastric carcinoma after curative resection is mostly due to recurrence. The most common recurrence is peritoneal dissemination, which represents 33 to 50% of total recurrence after curative gastrectomy. Since survival after peritoneal dissemination is very poor, selection of high-risk patients for further management after resection may contribute to better survival. METHODOLOGY: Based on a prospective database, a total of 1,092 patients with gastric carcinoma who underwent curative resection were included in this study. The incidence of peritoneal recurrence, disease-free interval and survival after peritoneal recurrence were determined. The clinicopathological factors including sex, age, tumor location, size, gross appearance, histological findings, depth of tumor invasion, lymph node status, tumor cell infiltration pattern were analyzed to see if there is any relationship with peritoneal dissemination. RESULTS: The incidence of peritoneal recurrence after curative resection was 13.46%. The mean disease-free interval was 14.2 months and the survival after peritoneal recurrence was 4.9 months in average. Almost all the clinicopathological factors were related with peritoneal recurrence, but only depth of tumor invasion, gross appearance and tumor infiltration pattern are closely associated with peritoneal tumor dissemination after multivariate analyses. CONCLUSIONS: Since the prognosis after peritoneal recurrence is so poor, selection of high-risk patients for further management after gastrectomy may be based on these three factors.     

Wound recurrence following laparoscopic colon cancer resection

INTRODUCTION: Multiple case reports have suggested that laparoscopic resection of colon cancer may alter the pattern or incidence of cancer recurrence. All reports lack a significant denominator to evaluate the incidence of surgical wound recurrence. We hypothesized that wound recurrence incidence is not increased by laparoscopic resection of colon cancer. METHODS: A prospective registry was initiated under the auspices of The American Society of Ccolon and Rectal Surgeons, American College of Surgeons, and Society of American Gastrointestinal Endoscopic Surgeons in 1992. Patients having laparoscopic colon resection were voluntarily entered and followed until June 1995. Recurrences were evaluated by the primary surgeon and reported to the registry. RESULTS: A total of 504 patients treated for cancer were identified in the registry. A minimum follow-up of one year was obtained for 480 of 493 evaluable patients (97.4 percent). Wound recurrence was identified in five patients (1.1 percent). Recurrence status was unknown in 18 patients (3.8 percent). CONCLUSION: Wound recurrence rates appear to be low. Although length of follow-up is limited, patterns of recurrence from previous studies suggest that 80 percent of recurrences should have occurred within one year. Given the limitations of a Phase II study, the hypothesis that recurrence rate is low is supported. However, prospective randomized trials are needed to establish if any difference in wound recurrence rates after laparoscopic or open resection of colorectal cancer exists.     

Predictive factors for local recurrence and incomplete resection of early gastric cancer treated by endoscopic resection: A Western experience

BACKGROUND:

Early gastric cancer (EGC) is defined as adenocarcinoma limited to the mucosa or submucosa regardless of lymph node involvement. Local EGC recurrence rates have been described in up to 6% of cases.

OBJECTIVES:

To evaluate predictive factors for incomplete resection and local recurrence of EGC treated by endoscopic mucosal resection (EMR) that was followed up for at least one year.

METHODS:

From June 1994 to December 2005, 46 patients with EGC underwent EMR. Possible predictive factors for incomplete endoscopic resection and local recurrence were identified by medical chart analysis. Demographic, endoscopic and histopathological data were retrospectively evaluated. EMR was considered complete or incomplete. Patients from the complete resection group were divided into subgroups (with and without local EGC recurrence).

RESULTS:

Complete resection was possible in 36 cases (76.6%). Predictive factors for incomplete resection were tumour location (P=0.035), histological type (P=0.021), lesion size (P=0.022) and number of resected fragments (P=0.013). On multivariate analysis, undifferentiated histological type (OR 0.8; 95% CI 0.036 to 0.897) and number of resected fragments (OR 7.34; 95% CI 1.266 to 42.629) were independent predictive factors for incomplete resection. In the complete resection group, a larger lesion size was associated with a higher the number of resected fragments (P=0.018). Local recurrence occurred in nine cases (25%). Use of the cap technique was the only predictive factor for local recurrence in five of seven cases (71.4%) (P=0.006).

CONCLUSIONS:

A larger lesion size was associated with a higher number of resected fragments. Undifferentiated adenocarcinoma and piecemeal resection were predictive factors for incomplete resection. Technique type was a predictive factor for local EGC recurrence.     

Predicting recurrence patterns after resection of hepatocellular cancer

Background

The reliable prediction of hepatocellular carcinoma (HCC) recurrence patterns potentially allows for the prioritization of patients for liver resection (LR) or transplantation.

Objectives

The aim of this study was to analyse clinicopathological factors and preoperative Milan criteria (MC) status in predicting patterns of HCC recurrence.

Methods

During 1992–2012, 320 patients undergoing LR for HCC were categorized preoperatively as being within or beyond the MC, as were recurrences.

Results

After a median follow-up of 47 months, 183 patients developed recurrence, giving a 5-year cumulative incidence of recurrence of 62.5%. Patients with preoperative disease within the MC had better survival outcomes than those with preoperative disease beyond the MC (median survival: 102 months versus 45 months; P < 0.001). Overall, 31% of patients had preoperative disease within the MC and 69% had preoperative disease beyond the MC. Estimated rates of recurrence-free survival at 5 years were 61.8% for all patients and 53.8% for patients with initial beyond-MC status. Independent factors for recurrence beyond-MC status included preoperative disease beyond the MC, the presence of microsatellite or multiple tumours and lymphovascular invasion (all: P < 0.001). A clinical risk score was used to predict survival and the likelihood of recurrence beyond the MC; patients with scores of 0, 1, 2 and 3 had 5- year incidence of recurring beyond-MC of 9.0%, 29.5%, 48.8% and 75.4%, respectively (P < 0.0001).

Conclusions

Regardless of initial MC status, at 5 years the majority of patients remained disease-free or experienced recurrence within the MC after LR, and thus were potentially eligible for salvage transplantation (ST). Incorporating clinicopathological parameters into the MC allows for better risk stratification, which improves the selection of patients for ST and identifies patients in need of closer surveillance.     

Anastomotic recurrence after sphincter-saving resection for rectal cancer

A retrospective study of anastomotic recurrence after sphincter-saving resection for rectal cancer is presented. During the 21 years from 1962 to 1982, 273 patients with rectal cancer underwent sphincter-saving resection and 30 (11 percent) of them had anastomotic recurrences. Computer analysis of 69 variables was undertaken to identify factors contributing to the anastomotic recurrence, with special reference to the length of distal clearance of the bowel. There was no significant correlation between the incidence of recurrence and the length of distal clearance of the bowel, if the latter was over 2 cm. There appears to be justification for carrying out a curative sphincter-saving operation for cases in which more than a 2-cm distal margin can be afforded. However, for cancers of the infiltrating type, annular growths, invasion to adjacent organs or mucinous features, a more extensive distal clearance of the bowel is necessary, and the Miles operation should be performed.     

Abdominosacral resection for locoregional recurrence rectal cancer]

Local recurrence of rectal cancer occurs in up to 30% after radical surgical treatment and it represents a formidable challenge to surgeons and oncologist, presenting most of times within two years after proper therapy have been provided. Although chemoradiation therapy reduces the rate of it, it has no any impact in survival. On the other hand, it has been proved that almost 50% of recurrences are without evidence of systemic disease and amenable to surgical resection, by the time of diagnose. For this reason there are a number of authors currently arguing a more agressive treatment for this entity in order to improve survival and reduces recurrence rate. Radical pelvic surgery for recurrent rectal cancer should be performed primarily with curative intent in patients without evidence of extrapelvic or distant spread. Abdominosacral resection represents a therapeutic option for patients with specific type of pelvic recurrence providing, according to figures from the most experienced groups, an actuarial survival rates of almost 33% at four years in a group of patients with a life expectancy, by other means, round seven months. We present our experience with this surgical procedure in Surgical Oncology Department at Roger Williams Cancer Center in Providence, leads by HJ. Wanebo.     

Abdominal wall recurrence after colorectal resection for cancer

PURPOSE: Disease recurrence in the abdominal wall from a primary colorectal cancer is a poorly studied and little understood phenomenon that has received renewed attention after the recognition of port site metastases in patients after laparoscopic colorectal resections. The purpose of the present study was to define the clinical, pathologic, and management issues in patients with abdominal wall metastases from colorectal cancer. METHODS: Patients presenting to Memorial Sloan-Kettering Cancer Center with a diagnosis of colorectal cancer were entered into a prospective database beginning in 1986. Review of this database showed that 31 patients presenting with recurrent disease in the abdominal wall were managed surgically at the institution between 1986 and 1998. RESULTS: A total of 31 patients (19 males) with a median age of 67 (range, 45–86) years presented with recurrent disease between 7 and 183 (median, 24) months after primary surgery. Primary tumors were located in the right colon in 17 patients, left colon in 2 patients, sigmoid colon in 7 patients, and rectum in 3 patients. Nineteen percent of primary tumors were perforated, 45 percent were poorly differentiated, 92 percent were transmural (T3 or T4), and 51 percent had lymph node metastases at presentation. Twenty-two patients presented with a symptomatic abdominal wall mass, whereas recurrence in the abdominal wall was found incidentally in 9 patients undergoing laparotomy. Four patients had isolated abdominal wall disease, whereas the remaining 27 were found to have associated intra-abdominal disease. Six patients who were left with residual intra-abdominal cancer after abdominal wall resection had a median survival time of four months. Twenty-five patients underwent a histologically complete resection of recurrence restricted to the abdominal wall alone (n=4; median survival time, 18 months), abdominal wall and in continuity resection of adherent viscera (n=15; median survival time, 12.5 months), or resection of abdominal wall and intra-abdominal recurrence at a distant site (n=6; median survival time, 22 months, although only 1 patient remained alive with disease). The actual two-year and five-year disease-free survival rates were 16 and 3 percent, respectively. CONCLUSION: Abdominal wall metastases are often indicators of recurrent intra-abdominal cancer; however, aggressive resection in patients with disease restricted to the abdominal wall and associated adherent viscera can result in local disease control with little morbidity and no mortality.Supported by the Eru Pomare Fellowship from the Health Research Council of New Zealand.Presented at the Annual Scientific Session of SAGES, Atlanta, Georgia, March 29 to April 1, 2000.     

Pattern of recurrence after esophageal resection for cancer.

BACKGROUND/AIMS: Surgery is still the main treatment option for esophageal cancer; however, long-term survival has remained poor, even when a curative operation is performed. The present study was undertaken to analyze the pattern and time of recurrence after a curative esophagectomy. METHODOLOGY: We studied 53 patients who underwent curative esophageal resection for cancer between 1985 and 1994. We examined number and pattern of recurrences, time after surgery, and any factor with contribution to carcinoma recurrence. RESULTS: During the follow-up period, 34 patients had tumor recurrence. The disease-free interval was 12.7 months (SD = 9.8). Twenty patients (58.9%) developed extrathoracic tumor recurrence and 23 patients (67.6%) intrathoracic. In 3 cases an esophageal stump recurrence was presented. Thirteen patients were considered for palliative treatment after recurrence. The 5-year survival rate was 13%, with median survival time between recurrence and death, 4.1 months. The recurrence of disease was always before 40 months after surgery. Any significant difference related with recurrence was observed between the analyzed factors. CONCLUSIONS: The majority of recurrences are developed before 2 years. Neoplastic recurrence is most common at the mediastinum. Palliative treatments after recurrence do not modify the progression of tumor.     

Prognosis of gastric cancer patients with node-negative metastasis following curative resection: outcomes of the survival and recurrence

BACKGROUND: The purpose of the present study was to provide valuable prognostic information on lymph node-negative gastric cancer patients following curative resection. METHODS: Data from 112 lymph node-negative gastric cancer patients who underwent curative resection were reviewed to identify the independent factors of overall survival and recurrence. RESULTS: The five-year survival rate of lymph node-negative gastric cancer patients was 85.7%, and recurrence was identified in 25 patients after curative surgery. The five-year survival rate of lymph node-negative gastric cancer patients was higher than that of lymph node-positive gastric cancer patients (P<0.001). Recurrence in lymph node-negative gastric cancer patients was less than that of lymph node-positive gastric cancer patients (P=0.001). The median survival after recurrence of lymph node-negative gastric cancer patients was longer than that of lymph node-positive gastric cancer patients (P=0.021). Using multivariate analyses, the following results were determined for lymph node-negative gastric cancer patients: sex, operative type and the presence of serosal involvement were independent factors of overall survival; and lymphadenectomy, number of dissected nodes and the presence of serosal involvement were independent factors of recurrence. CONCLUSIONS: The prognosis of lymph node-negative gastric cancer patients was better than that of lymph node-positive gastric cancer patients. Male sex, subtotal gastrectomy and nonserosal involvement should be considered to be the favourable predictors of postoperative long-term survival of lymph node-negative gastric cancer patients. Conversely, limited lymphadenectomy, few dissected nodes and serosal involvement should be considered to be risk factors of postoperative recurrence of lymph node-negative gastric cancer patients.     

Length of negative resection margin does not affect local recurrence and survival in the patients with gastric cancer

AIM:To investigate the influence of the resection margin on local recurrence and survival in gastric cancer patients.METHODS:We reviewed the medical records of 1788patients who had undergone gastrectomy for gastric cancer at the Seoul National University Bundang Hospital,South Korea,between May 2003 and July 2009.The patients were divided into early and advanced gastric cancer groups.In each group,we analyzed the relationship between clinicopathologic factors and survival outcomes,and compared the hazard rates of event occurrence between patients with resection margins above and below the cut-off value,using a Cox proportional hazard model.RESULTS:The early and advanced gastric cancer groups included 1001 and 787 patients,respectively.The hazard rates of event occurrence did not significantly differ between the patients with resection margins above the cut-off value and those with resection margins below the cut-off value(P>0.05,in all comparisons).Based on the multivariable analyses,the proximal and distal resection margins were not significantly associated with survival outcomes and local recurrence(P>0.05,in all analyses).CONCLUSION:The proximal or distal resection margins did not affect the prognosis of patients with gastric cancer if the margins were pathologically negative.     

Local tumor recurrence after curative resection for rectal cancer

Local tumor recurrence rates after curative rectal cancer surgery with the end-to-end anastomosis stapler (EEA^®) are reportedly high. Therefore, a retrospective review in ten Yale-affiliated hospitals was undertaken to establish the outcome of surgical resection for rectal cancer in this patient population. Of those 373 patients who had had curative resections, 192 (52 percent) were abdominoperineal resections (APR); 105 patients (28 percent) had restorative resections with sutured anastomoses, and the EEA stapler was used in 76 patients (20 percent). There was an equal distribution of tumors in the various Dukes' stages in all three procedures. Local tumor recurrence was: APR 19 percent, SUT 17 percent, and EEA 24 percent, but local tumor recurrence was more frequent after EEA than APR for tumors 7 to 10 cm from the anal verge (32 vs. 13 percent, respectively,P<0.05), and the time to recurrence was least in EEA patients. It is concluded that local tumor recurrence is higher than expected for all three procedures and that the EEA stapler was associated with a greater risk of local tumor recurrence. These findings are attributed to surgeon-related technical operative factors rather than to the nature of the tumors themselves.     

Patterns of recurrence after resection of gallbladder cancer without routine extrahepatic bile duct resection

Objective

Routine extrahepatic bile duct (EBD) resection in non-jaundiced patients with gallbladder cancer (GBC) is controversial. The aim of this study was to retrospectively analyse patterns of recurrence in patients who underwent resection of GBC without routine EBD resection.

Methods

This analysis referred to 58 patients who had undergone explorative laparotomy for GBC during 2000–2012 at a single, tertiary referral centre. Overall survival, time to recurrence, and patterns of recurrence were assessed in patients who underwent conventional negative-margin (R0) resection without routine EBD resection.

Results

Of 58 patients submitted to explorative laparotomy for GBC, 26 (45%) patients underwent R0 resection without EBD resection (tumour stage T1b in five patients, T2 in 17, T3 in three, and T4 in one). The 3-year survival rate among these patients was 78% at a median follow-up of 33 months (range: 13–127 months). Seven patients developed recurrent disease at a median of 9 months (range: 2–25 months) after resection. No patients developed isolated recurrent disease at the EBD.

Conclusions

Of 26 patients resected for GBC, none developed isolated recurrent disease at the EBD after conventional resection of GBC without EBD resection. This finding suggests that routine EBD resection is of no additional value.