Clinical benefit of surgery for stage IV colorectal cancer with synchronous peritoneal metastasis

Background

Peritoneal metastasis is well-known as a poor prognostic factor in patients with colorectal cancer. It is important to improve the prognosis of patients with colorectal cancer and synchronous peritoneal metastasis. This study aimed to clarify the factors affecting R0 resection and the prognosis of colorectal cancer patients with synchronous peritoneal metastasis.

Methods

We investigated the data of patients with stage IV colorectal cancer between 1991 and 2007 in 16 hospitals that were members of the Japanese Society for Cancer of the Colon and Rectum.

Results

Of the 564 colorectal cancer patients with synchronous peritoneal metastases, 341 also had hematogenous metastases. The 5-year overall survival rates in patients with and without R0 resection were 32.4 and 4.7 %, respectively. A Cox proportional hazards model showed that histologic type of poorly differentiated adenocarcinoma, regional lymph node metastasis, liver metastasis, chemotherapy after surgery, R0 resection, the Japanese classification of peritoneal metastasis, and the size of peritoneal metastases were independent prognostic factors. Of the 564 patients, 28.4 % had R0 resection. The Japanese classification of peritoneal metastasis (P1–P2, p = 0.0024) and absence of hematogenous metastases (p < 0.0001) were associated with R0 resection.

Conclusions

P1–P2 peritoneal metastasis and the absence of hematogenous metastasis were the most favorable factors benefiting from synchronous resection of peritoneal metastasis. In addition, chemotherapy after surgery was essential.     

Therapeutic options for peritoneal metastasis arising from colorectal cancer

Peritoneal metastasis is a common sign of advanced tumor stage, tumor progression or tumor recurrence in patients with colorectal cancer. Due to the improvement of systemic chemotherapy, the development of targeted therapy and the introduction of additive treatment options such as cytoreductive surgery(CRS) and hyperthermic intraperitoneal chemotherapy(HIPEC), the therapeutic approach to peritoneal metastatic colorectal cancer(pm CRC) has changed over recent decades, and patient survival has improved. Moreover, in contrast to palliative systemic chemotherapy or best supportive care, the inclusion of CRS and HIPEC as inherent components of a multidisciplinary treatment regimen provides a therapeutic approach with curative intent. Although CRS and HIPEC are increasingly accepted as the standard of care for selected patients and have become part of numerous national and international guidelines, the individual role, optimal timing and ideal sequence of the different systemic, local and surgical treatment options remains a matter of debate. Ongoing and future randomized controlled clinical trials may help clarify the impact of the different components, allow for further improvement of patient selection and support the standar-dization of oncologic treatment regimens for pm CRC. The addition of further therapeutic options such as neo-adjuvant intraperitoneal chemotherapy or pressurized intraperitoneal aerosol chemotherapy, should be investig-ated to optimize therapeutic regimens and further improve the oncological outcome.     

Second primary cancer after surgery for colorectal cancer without lymph node metastasis

BACKGROUND/AIMS: Colorectal cancer patients without lymph node metastasis usually show a favorable prognosis with low recurrence rates; however, there is an increased risk of the development of a second primary cancer. Understanding the features of a second primary cancer is important to establish an effective postoperative follow-up program for colorectal cancer without lymph node metastasis. METHODOLOGY: The clinicopathological data on 801 patients with Dukes' A and Dukes' B colorectal cancer were examined in respect to second primary cancer. RESULTS: In patients with Dukes' A cancer, the incidences of recurrence and second primary cancer were similar. When tumor invasion was limited within subserosa in Dukes' B patients, the incidence of a second primary cancer was almost two-thirds that of recurrence. More than half of the second primary cancers again developed from the colorectum, followed by stomach and lung. CONCLUSIONS: When colorectal cancer patients without lymph node metastasis show tumor invasion limited within the subserosa, postoperative follow-up should monitor a balance of recurrence with a second primary cancer.     

Radiofrequency ablation as treatment for pulmonary metastasis of colorectal cancer

Radiofrequency ablation(RFA)causes focal coagulation necrosis in tissue.Its first clinical application was reported in 2000,and RFA has since been commonly used in both primary and metastatic lung cancer.The procedure is typically performed using computed tomography guidance,and the techniques for introducing the electrode to the tumor are simple and resemble those used in percutaneous lung biopsy.The most common complication is pneumothorax,which occurs in up to 50%of procedures;chest tube placement for pneumothorax is required in up to 25%of procedures.Other severe complications,such as pleural effusion requiring chest tube placement,infection,and nerve injury,are rare.The local efficacy depends on tumor size,and local progression after RFA is not rare,occurring in 10%or more of patients.The local progression rate is particularly high for tumors>3 cm.Repeat RFA may be used to treat local progression.Short-to mid-term survival after RFA appears promising and is approximately 85%-95%at 1 year and 45%-55% at 3 years.Long-term survival data are sparse.Better survival may be expected for patients with small metastasis,low carcinoembryonic antigen levels,and/or no extrapulmonary metastasis.The notable advantages of RFA are that it is simple and minimally invasive;preserves pulmonary function;can be repeated;and is applicable regardless of previous treatments.Its most substantial limitation is limited local efficacy.Although surgery is still the method of choice for treatment with curative intent,the ultimate application of RFA may be to replace metastasectomy for small metastases.Randomized trials comparing RFA with surgery are needed.     

Intra-operative peritoneal lavage for colorectal cancer

Free cancer cells can be detected in peritoneal fluid at the time of colorectal surgery.Peritoneal lavage in colorectal surgery for cancer is not used in routine,and the prognostic significance of intraperitoneal free cancer cells(IPCC)remains unclear.Data concerning the technique of peritoneal lavage to detect IPCC and its timing regarding colorectal resection are scarce.However,positive IPCC might be the first step of peritoneal spread in colorectal cancers,which could lead to early specific treatments.Because of the important heterogeneity of IPCC determination in reported studies,no treatment have been proposed to patients why positive IPCC.Herein,we provide an overview of IPCC detection and its impact on recurrence and survival,and we suggest further multi-institutional studies to evaluate new treatment strategies.     

NOSES结直肠癌根治术后腹腔冲洗液肿瘤细胞学检测及细菌培养结果分析

目的分析经自然腔道取标本手术（NOSES）完全腹腔镜下结直肠癌根治术后患者腹腔冲洗液的肿瘤细胞学检测、细菌培养的结果及其临床意义。 方法留取2016年1月至2018年4月湘雅医院普外结直肠肛门外科30例行NOSES完全腹腔镜下结直肠癌根治术患者术后腹腔冲洗液,分装两份,分别送病理科查找肿瘤细胞和检验科行细菌培养,收集肿瘤细胞学检测及细菌培养结果,并与国内外文献报道的开腹和常规腹腔镜结直肠癌根治术腹腔冲洗液的肿瘤细胞检测及细菌培养结果比较分析。 结果30例NOSES完全腹腔镜下结直肠癌根治术患者的腹腔冲洗液肿瘤细胞阳性的患者0例,阳性率0%（0/30）;细菌培养阳性的患者有10例,阳性率33.3%（10/30）;至目前为止30例NOSES患者术后均未出现盆/腹腔感染及盆/腹腔肿瘤的复发转移。这一结果与国内外文献报道的开腹及常规腹腔镜结直肠癌根治术后腹腔冲洗液的肿瘤细胞学检查（0%~45.5%）和细菌培养结果（20%~32.5%）相近。 结论与开腹和常规腹腔镜结直肠癌根治术相比,NOSES结直肠癌根治术未增加患者术后盆腹腔感染及未促进肿瘤细胞种植转移,符合恶性肿瘤根治术的无菌无瘤原则,值得临床推广应用。     

Peritoneal lavage cytology and carcinoembryonic antigen determination in predicting peritoneal metastasis and prognosis of gastric cancer

AIM: To evaluate the role of peritoneal lavage cytology (PLC) and carcinoembryonic antigen (CEA) determination of peritoneal washes (pCEA) in predicting the peritoneal metastasis and prognosis after curative resection of gastric cancer. METHODS: PLC and radioimmunoassay of CEA were performed in peritoneal washes from 64 patients with gastric cancer and 8 patients with benign diseases. RESULTS: The positive rate of pCEA (40.6%) was significantly higher than that of PLC (23.4%) (P<0.05). The positive rates of PLC and pCEA correlated with the depth of tumor invasion and lymph node metastasis (P<0.05). pCEA was found to have a higher sensitivity and a lower false-positive rate in predicting peritoneal metastasis after curative resection of gastric cancer as compared to PLC. The 1-, 3-, and 5-year survival rates of patients with positive cytologic findings or positive pCEA results were significantly lower than those of patients with negative cytologic findings or negative pCEA results (P<0.05). Multivariate analysis indicated that pCEA was an independent prognostic factor for the survival of patients with gastric cancer. CONCLUSION: Intraoperative pCEA is a more sensitive and reliable predictor of peritoneal metastasis as well as prognosis in patients with gastric cancer as compared to PLC method.     

肿瘤标记物结合病理对结直肠癌腹膜转移预判的研究

目的探讨血清CEA、CA19-9、CA125结合临床病理对术前判断是否具有结直肠癌腹膜转移的意义。 方法选取2014年1月至2017年10月在哈尔滨医科大学附属第二临床医学院行手术治疗的结肠癌及肿瘤位于直肠腹膜反折以上的直肠癌患者,共1 215例。其中,无腹膜转移的患者988例,同时性腹膜转移的患者227例,比较两组临床资料。 结果高分化腺癌、中分化腺癌、低分化腺癌、黏液腺癌、印戒细胞癌发生腹膜转移的几率分别为0、5.4%、35.6%、45.3%、75%,病理恶性程度越高越容易出现腹膜转移。血清CEA、CA19-9及CA125三者对结直肠癌腹膜转移的辅助诊断中,以CA125最为敏感,敏感度为100%,曲线下面积为0.897,CA125的这两项明显高于CEA及CA19-9,其特异度与CEA接近,较CA19-9低。CA19-9的特异度最高,为86%,但其灵敏度（47%）、曲线下面积（0.669）为三者中最低。CEA、CA19-9、CA125增高越明显,发生腹膜转移的几率就越大,当CEA＋CA125增高或CA125＋CA19-9增高或CEA＋CA125＋CA19-9增高时,发生腹膜转移的几率分别为65.7%、73.1%、77.3%。 结论通过CEA、CA19-9、CA125结合临床病理等检查的辅助,可以提高术前诊断结直肠癌腹膜转移的准确率,有助于术前判断患者的病情及预后。     

Utility valuations for outcome states of colorectal cancer

OBJECTIVE: Utilities for the outcome states of colorectal cancer (CRC) must be measured to evaluate the cost-utility of screening and surveillance strategies for this disease. We sought to measure utilities for stage-dependent outcome states of CRC. METHODS: We identified persons who had previously undergone removal of colorectal adenoma. We conducted individual interviews in which these participants were presented with stage-dependent outcome states and were asked to assess utilities for them using the standard gamble technique. RESULTS: A total of 90 participants were interviewed; nine were excluded, leaving 81 for analysis. We obtained the following utility valuations: stage I rectal or stage I/II colon cancer (mean 0.74, median 0.75); stage III colon cancer (mean 0.67, median 0.75); stage II/III rectal cancer without ostomy (mean 0.59, median 0.60), stage II/III rectal cancer with ostomy (mean 0.50, median 0.55), stage IV rectal or colon cancer (mean 0.25, median 0.20). These valuations were statistically different from each other. CONCLUSIONS: We measured utilities for stage-dependent outcome states of CRC in a sample of persons who had previously undergone removal of colorectal adenoma. We found that our participants were able to differentiate between the presented outcome states and assigned lower utility to increasingly morbid states. Our results show that stage-dependent morbidity is an important consideration in CRC and should be incorporated into any decision analysis model evaluating the cost-effectiveness of CRC screening or surveillance.     

结直肠癌伴同时性肝转移腹腔镜手术的护理及配合

肝脏是结直肠癌患者最易转移的靶器官,笔者对所在中心结直肠癌同时性肝转移患者腹腔镜一期切除术手术中的护理配合进行总结和分析,旨在让护理团队加深对此类型手术的认识,更新理念,提高配合的流畅度,使该手术的护理配合模式规范化、合理化、可推广化。提高护理团队对此类手术的配合熟练度,从而促使手术顺利进行,缩短手术时间,最终使患者获益。     

Intrabiliary metastasis in colorectal cancer

Endobiliary metastasis of colorectal cancers are rare. We report a 36 years-old patient, operated on 5 years ago for a left colon cancer with a left colectomy. He consulted for pain in the upper right quadrant without fever nor jaundice. Ultra-sound, CTscan, RMI and PET led to the diagnosis of endobiliary metastasis and the patient underwent a right hepatectomy. A review of the literature of the endobiliary metastasis follows this case-report. These tumours can mimic intrahepatic cholangiocarcinoma in clinical presentation, imaging or even histological examinations. The main goal of the imaging explorations is to establish the resecability of such tumours. Patients with endobiliary metastasis seem to have better survival than patients with intrahepatic metastasis.     

Hepatectomy for liver metastasis of colorectal cancer

Objective  The objective of this study was to investigate whether hepatic resection (HR) can increase the survival of liver metastasis of colorectal cancer (CRC). Materials and methods  CRC patients (n = 669) with liver metastasis treated at the Zhongshan Hospital, Fudan University from 1/2000 to 7/2007 were included in the study to investigate the relationship between HR and cancer survival. Results  CRC patients (n = 669) with liver metastases who had primary tumor resection were grouped in synchronous liver metastasis (SLM; 56.7%, n = 379) and metachronous liver metastasis (MLM) groups (43.3%, n = 290). Hepatic resection rates were lower (32.5%, n = 123) in the SLM than the MLM group (44.8%, n = 130, P < 0.05). The 30-day mortality rate in the MLM (2.3%) was significantly lower than SLM (2.4%) groups. The 5-year survival rates (36.6%) was same compared to SLM group (33.1%, P > 0.05). One-, 2-, and 3-year survival of stages I and II operation cases were 92.5% vs 86.5%, 0.7% vs 58.0%, and 42.1% vs 44.9% (P > 0.05) in the SLM group, respectively. Recurrence after first hepatic resection associated with a 2.23-fold increased risk of death (P < 0.01). Incision margins larger than 1 cm and HR for recurrence associated with 34% and 27% (P < 0.05) decreased death risk. Conclusions  Hepatic resection could help the survival of liver metastasis of colorectal cancer, and stage I surgery is safe for this disease. Xu Jianmin, Wei Ye, and Zhong Yunshi contributed equally to this paper.     

Hepatic resection for metastasis from colorectal cancer

Summary Twenty-five patients who had hepatic metastases from carcinomas of the colon and rectum had resection for cure at Memorial Hospital, with a determinate five-year survival rate of 40 per cent, and 10-year survival rate of 28 per cent. Most of the hepatic metastatic lesions were solitary, small, and peripheral, and were treated with simple wedge resection. These favorable results justify an aggressive approach to solitary metastatic lesions in the liver.     

Curative surgery for colorectal cancer

PURPOSE: The long-term prognosis after curative surgery for colorectal cancer was evaluated in relation to age and life expectancy as a possible basis for assessing the risk to benefit ratios in the elderly. METHODS: Data relating to 1,256 patients operated on from 1976 to 1994 were stored in a computer database prospectively from 1987. Patients were subdivided into four age groups (A=<60 years; B=60–69; C=70–79; D=80). Distribution of general contraindications to curative surgery was examined. In the 869 patients who underwent curative treatment (A=206; B=256; C=289; D=118), distribution of tumor stage and elective/emergency surgery and the operative mortality rate were evaluated. Crude and age-corrected survival curves were calculated in 794 patients. The median crude survival of each group was related by gender and tumor stage to demographic life expectancy, assuming as relative median survival index the ratio between the two values. RESULTS: General contraindications to curative surgery increased significantly with age. The operative mortality rate was higher in Group D than in Groups A, B, plus C over the total series (P<0.001) and in both elective (P<0.001) and emergency surgery (P<0.05). Intergroup analysis of long-term survival rates showed significant differences between crude (P=0.0057) but not age-corrected (P=0.66) curves. The relative median survival index increased with age, up to approximately 1 in the local stages of Groups C and D. CONCLUSIONS: To evaluate long-term results, elderly patients should be compared with unaffected, same-age subjects. Because the risks may be very high, the surgical policy in the elderly should be carefully weighed and related to life expectancy and actual results.Supported in part by grants from the Ministero dell'Università e della Ricerca Scientificae Tecnologica, Repubblica Italiana.