Assessing the effectiveness of mesorectal excision in rectal cancer

PURPOSE: The aim of this study was to determine whether the number of involved or uninvolved lymph nodes in resected specimens can be used to predict the effectiveness of surgical resection for rectal cancer. METHODS: Local recurrence and survival rates for 118 patients undergoing curative resection for rectal carcinoma, without adjuvant therapy, were retrospectively studied. RESULTS: Mean follow-up was 62±37 months. Mean number of involved or uninvolved lymph nodes per resected specimen was 12±7. Overall local recurrence rate was 15.2 percent. In patients without involved lymph nodes (N0 patients) and with T1 or T2 tumors, the local recurrence rate ranged from 0 to 8 percent (not significant), depending on the number of lymph nodes on the specimen. In patients without involved lymph nodes and those with T3 tumors, the actuarial survival rate at ten years was significantly lower (P<0.05), and the local recurrence rate was higher (P<0.02) in patients with fewer than ten lymph nodes than in those with more than ten nodes. In patients with involved lymph nodes, the mean number of nodes on the resected specimen correlated closely with the mean number involved by the tumor. CONCLUSION: The assessment of the effectiveness of rectal excision for cancer is in part helped by the number of involved or uninvolved lymph nodes found on the resected specimen. This is of particular interest in patients without involved lymph nodes and those having infiltrating T3 tumors, for whom the long-term survival and local recurrence rates were significantly better when more than ten lymph nodes were present. On the other hand, when fewer than ten nodes were found, whatever the cause, adjuvant radiotherapy had to be considered, because of the high risk of local failure rate.     

Predictive factors of advanced recurrence after curative resection of small hepatocellular carcinoma

Background: The tumour recurrence rate after resection is still high even in patients with small hepatocellular carcinoma (HCC). The advanced patterns of recurrence occasionally occur after resection. In this study, we analysed the clinical and histological characteristics of small HCC and evaluated the predictive factors of advanced tumour recurrence. Methods: One hundred and sixty‐five patients underwent resection of small HCC measuring 3 cm or less in greatest dimension. Patterns of tumour recurrences were classified into advanced recurrence and minor recurrence based on size, number, vascular invasion and extrahepatic metastasis of recurrent tumour. We created a simple index to closely evaluate the malignant potential of small HCC, named α‐foetoprotein–size ratio index (ASRI). Results: Overall tumour recurrence was significantly associated with tumour multiplicity (P<0.001) and ASRI (P=0.001). Tumour multiplicity, ASRI and tumour differentiation were independent and significant predictive factors of advanced recurrences. The overall survival rates were lower in the advanced recurrence group than the minor recurrence or the no recurrence group. Conclusions: Patients with advanced recurrences have a poor prognosis, although they have undergone curative resection of small HCC. On the other hand, patients with minor recurrences have a relatively good prognosis. ASRI was a useful index to predict advanced recurrence after curative resection of small HCC. The therapeutic management to prevent advanced recurrences is needed.     

Predictors of survival in recurrent rectal cancer after resection and intraoperative radiotherapy

PURPOSE: This study was designed to determine predictors of survival after surgery and intraoperative radiotherapy for recurrent rectal cancer. METHODS: From a prospective database, 634 patients undergoing resection for recurrent rectal cancer between January 1990 and June 2000 were identified. Of these, 111 received intraoperative radiotherapy with curative intent, and 100 were available for follow-up. Clinicopathologic variables from both the primary and recurrent operations were evaluated as predictors of disease-free and disease-specific survival by multivariate Cox regression and log-rank test. RESULTS: There were 54 males and 46 females, with a median age of 57 (range, 37–83) years. With a median follow-up of 23.2 months, 60 patients (60 percent) recurred: 20 (33 percent) locally, 27 (45 percent) distantly, and 13 (22 percent) at both sites. Of all variables analyzed, only complete resection with microscopically negative margins and the absence of vascular invasion in the recurrent specimen predicted improved disease-free and disease-specific survival (P < 0.01 for all). Median disease-free survival and median disease-specific survival were 31.2 and 66.1 months, respectively, for complete resection compared with 7.9 and 22.8 months for resection with microscopic or grossly positive margins (P < 0.01 for both). Median disease-free survival and median disease-specific survival were 6.4 and 16.1 months, respectively, in the presence of vascular invasion in the recurrent specimen compared with 23.3 and 57.3 months in the absence of vascular invasion (P < 0.01 and P < 0.05, respectively). Complete resection and the absence of vascular invasion were the only predictors of improved local control as well (P < 0.05 and P < 0.01, respectively). CONCLUSION: Resection with negative microscopic margins and absence of vascular invasion are independent predictors of local control and improved survival after resection and intraoperative radiotherapy for recurrent rectal cancer.     

Association Between Recurrence of Sporadic Colorectal Cancer,High Level of Microsatellite Instability,and Loss of Heterozygosity at Chromosome 18q

PURPOSE: Microsatellite instability and loss of heterozygosity of chromosomes 18q, 8p, and 4p are genetic alterations commonly found in colorectal cancer. We investigated whether these genetic markers allow for the stratification of patients with Stage II to III colorectal cancer into groups with different recurrence risks, and with different prognoses.METHODS: Tumors of 113 patients were evaluated for loss of heterozygosity of chromosomes 18q, 8p, and 4p and for microsatellite instability by use of six microsatellite markers. Genetic alterations involving each of these genetic markers were examined for association with disease recurrences and survival.RESULTS: Loss of heterozygosity of chromosomes 18q, informative in 96 percent of cases, in Stage III tumors was associated with higher risk of overall recurrence (P < 0.001), local recurrence (P < 0.001), distant metastases (P < 0.001), decreased overall survival (P = 0.002), and disease-free survival (P < 0.001). The recurrence rates and survival rates among patients with Stage II colorectal cancer were independent of loss of heterozygosity of chromosome 18q. Stage III and loss of heterozygosity of chromosome 8p also were associated with a higher risk of recurrences when these factors were considered individually. In multivariate analysis, only loss of heterozygosity of chromosome 18q was independently associated with risk of recurrences (P < 0.001) and with disease-free survival (P = 0.001). No correlation was observed between microsatellite instability and recurrence rates. However, microsatellite instability was associated with improved overall survival (P = 0.04) and with a longer disease-free interval (P = 0.002). Only in five cases (16.7 percent) was it possible to perform resection of recurrences; two of these patients had microsatellite instability tumor. In no cases was it possible to resect recurrence of tumors with loss of heterozygosity of chromosome 18q.CONCLUSIONS: Loss of heterozygosity of chromosome 18q is an informative genetic marker, which in resected Stage III colorectal cancer can be used to predict recurrences and survival. Microsatellite instability identified cases that, even in the case of recurrence, have a more favorable prognosis.Supported by a grant from Lega Italiana per la Lotta Contro i Tumori, Sezione di Parma.     

Indication and Benefit of Pelvic Sidewall Dissection for Rectal Cancer

Purpose This study was designed to clarify indication and benefit of pelvic sidewall dissection for rectal cancer. Methods The retrospective, multicenter study collected the data of rectal cancer patients who underwent surgery between 1991 and 1998 and were prospectively followed. Results Of 1,977 patients with rectal cancers, 930 underwent pelvic sidewall dissection without adjuvant radiotherapy. Positive lateral lymph nodes were found in 129. Multivariate analysis disclosed a significantly increased incidence of positive lateral lymph nodes in female gender, lower rectal cancers, non-well-differentiated adenocarcinoma, tumor size of ≥4 cm and T3-T4. The five-year survival rate for 1,977 patients was 79.7 percent. The survival of patients with positive lateral lymph nodes was significantly worse than that of Stage III patients with negative lateral lymph nodes (45.8 vs. 71.2 percent, P<0.0001). Multivariate analysis showed significantly worse prognosis in male gender, pelvic sidewall dissection, lower rectal cancers, T3-T4, perirectal lymph node metastasis, and positive lateral lymph nodes. During the median follow-up time of 57 months, recurrence developed in 19.7 percent: 17 percent in negative and 58.1 percent in positive lateral lymph nodes (P<0.0001). Local recurrence was found in 8 percent: 6.8 percent in negative and 25.6 percent in positive lateral lymph nodes (P<0.0001). Multivariate analysis disclosed that lower rectal cancers, non-well-differentiated adenocarcinoma, T3-T4, perirectal lymph node metastasis, and positive lateral lymph nodes were significantly associated with an increased local recurrence. Conclusions Positive lateral lymph node was the strongest predictor in both survival and local recurrence. Pelvic sidewall dissection may be indicated for patients with T3-T4 lower rectal cancers because of the greater provability of positive lateral lymph nodes. Study Group for Rectal Cancer Surgery of the Japanese Society for Cancer of the Colon and Rectum. Presented at the United States-Japan Clinical Trial Summit Meeting, Maui, Hawaii, February 10–13, 2005.     

Grade I chondrosarcoma of bone: the Münster experience

The surgical treatment of low-grade chondrosarcoma is controversial and the clinical course is difficult to predict. The purpose of this retrospective study was to review the authors’ experience with the surgical treatment of 80 patients with grade I chondrosarcoma. Intralesional resection margins increased the rate of local recurrence statistically significant (p < 0.001). However, there was no influence of the resection margins on the overall survival (p > 0.05) or on the rate of metastasis (p > 0.05). Conservative surgery for special indications with adjuvant use of PMMA (poly-methylmethacrylate) offers satisfying local tumour control rates in the long bones. However, after intralesional tumour resection of pelvic chondrosarcoma, four out of four patients developed a local recurrence, whereas no patient treated with wide resection margins received a local relapse, which has been statistically significant (p < 0.001). In conclusion, intralesional resection of a grade I chondrosarcoma has a higher overall risk of local recurrence but is not associated with a poorer survival. This procedure can be recommended for stage I A tumours of the long bones of the extremities. However, in pelvic lesions it should be avoided because of a 100% recurrence rate.     

Endoscopic and surgical resection of T1a/T1b esophageal neoplasms: A systematic review

AIM: To investigate potential therapeutic recommendations for endoscopic and surgical resection of T1a/ T1b esophageal neoplasms. METHODS: A thorough search of electronic databases MEDLINE, Embase, Pubmed and Cochrane Library, from 1997 up to January 2011 was performed. An analysis was carried out, pooling the effects of outcomes of 4241 patients enrolled in 80 retrospective studies. For comparisons across studies, each reporting on only one endoscopic method, we used a random effects meta-regression of the log-odds of the outcome of treatment in each study. "Neural networks" as a data mining technique was employed in order to establish a prediction model of lymph node status in superficial submucosal esophageal carcinoma. Another data mining technique, the "feature selection and root cause analysis", was used to identify the most impor-tant predictors of local recurrence and metachronous cancer development in endoscopically resected patients, and lymph node positivity in squamous carcinoma (SCC) and adenocarcinoma (ADC) separately in surgically resected patients. RESULTS: Endoscopically resected patients: Low grade dysplasia was observed in 4% of patients, high grade dysplasia in 14.6%, carcinoma in situ in 19%, mucosal cancer in 54%, and submucosal cancer in 16% of patients. There were no significant differences between endoscopic mucosal resection and endoscopic submucosal dissection (ESD) for the following parameters: complications, patients submitted to surgery, positive margins, lymph node positivity, local recurrence and metachronous cancer. With regard to piecemeal resection, ESD performed better since the number of cases was significantly less [coefficient: -7.709438, 95%CI: (-11.03803, -4.380844), P < 0.001]; hence local recurrence rates were significantly lower [coefficient: -4.033528, 95%CI: (-6.151498, -1.915559),P < 0.01]. A higher rate of esophageal stenosis was observed following ESD [coefficient: 7.322266, 95%CI: (3.810146, 10.83439), P < 0.001]. A significantly greater number of SCC pa     

Early recurrence in patients undergoing curative surgery for colorectal cancer: is it a predictor for poor overall survival?

Purpose

This study evaluated the prognostic value of early recurrence in patients who have undergone curative resection for colorectal cancer.

Methods

A total of 1,159 consecutive patients who underwent curative resection for non-metastatic colorectal cancer from December 1998 to December 2007 were reviewed. The predictive factors for early recurrence postoperatively and the prognostic factors were analyzed.

Results

Of the 1,159 patients, postoperative recurrence was identified in 280 (24.1 %) patients, and 96 (34.3 %) of the 280 patients with recurrence were designed as early recurrence (less than 1 year postoperatively). In multivariate analysis, tumor location, tumor diameter, number of retrieved lymph nodes, and lymphovascular invasion were the independent predictors for early recurrence. The early recurrence group had a significantly lower overall survival rate than that of the non-early recurrence group for both colon cancer (P?<?0.001) and rectal cancer (P?<?0.001). The overall survival rate for stage III tumors significantly differed between the early and non-early recurred patients (P?<?0.001), whereas the rate did not differ between the patients with stage II tumors (P?=?0.364). In multivariate analysis, early recurrence was an independent predictor for unfavorable overall survival. Moreover, differentiation, N category, and postoperative chemotherapy were the independent predictors for overall survival for the patients with both early and overall recurrence.

Conclusion

Poor survival was associated with early postoperative recurrence for patients who underwent curative resection for colorectal cancer. The use of adjuvant chemotherapy prolonged the survival of patients, irrespective of the interval of recurrence.     

Can pathological complete response in the primary tumour following pre-operative pelvic chemoradiotherapy for T3–T4 rectal cancer predict for sterilisation of pelvic lymph nodes, a low risk of local recurrence and the appropriateness of local excision?

Introduction Local excision is considered inappropriate treatment for T3–T4 rectal adenocarcinomas, as it cannot provide prognostic information regarding lymph node involvement and has a high risk of pelvic recurrence. Preoperative chemoradiation (CRT) studies in rectal cancer suggest that a pathological complete response (pCR) in the primary tumour provides an excellent long-term outcome. If downstaging to stage pT0 predicts a tumour response within the perirectal and pelvic lymph nodes, this may allow local excision to be performed without increased risk of pelvic recurrence. This retrospective study aimed to determine the incidence of involved lymph nodes following pCR (ypT0) after preoperative CRT and total mesorectal excision.Method The outcome and treatment details of 211 patients undergoing preoperative CRT for clinically staged T3–T4 unresectable rectal adenocarcinomas between 1993 and 2003 at Mount Vernon Hospital were reviewed.Results Data were recorded from the 143 patients who completed treatment with a median follow-up of 25 months. Twenty-three patients (18%) were found to have had a pCR. Four out of 23 patients (17%) had involved lymph nodes. No pelvic recurrences developed after a ypCR. Overall survival was similar for patients with ypT0 or residual tumour.Conclusion Pathological complete response in the primary tumour failed to predict a response in the perirectal lymph nodes (p=0.08). The degree of response predicted a lymph node response (p=0.02). The detection of ypCR identified patients with a low rate of pelvic recurrence. This may in the future allow selection of patients for whom local excision can be performed without a higher risk of local relapse.On behalf of the Mount Vernon Colorectal Cancer Network     

A National Study on Lymph Node Retrieval in Resectional Surgery for Colorectal Cancer

Purpose This study was designed to develop a mathematical model for predicting the number of lymph nodes harvested in bowel cancer resection specimens based on the current clinical practice in the United Kingdom. Methods Prospective clinical data were collected from 8,409 newly diagnosed bowel cancer patients presenting to 79 hospitals in Great Britain and Ireland during a variable 12-month period from 2000 to 2002. A two-level hierarchical regression model was used to identify predictors for lymph node harvest. The model was internally validated by comparing observed and model predicted lymph node harvest for patient subgroups. Results Inclusion criteria were satisfied by 5,164 patients. The average lymph node harvest was 11.7 nodes with significant between-center variability in lymph node harvest (range, 5.5–21.3 nodes). Increasing age, American Society of Anesthesiology grade, and preoperative radiotherapy were associated with a reduction of lymph node harvest (P < 0.001). Abdominoperineal resection of the rectum and transverse colectomy were the lowest yield procedures for lymph node harvest. Independent predictors of lymph node harvest were age, American Society of Anesthesiology grade, Dukes stage, operative urgency, type of resection, and preoperative radiotherapy. When tested, the model was found to accurately predict lymph node harvest for group statistics (comparison of observed and model predicted lymph node harvest F_1,5154 = 0.63; P = 0.427). Conclusions The results of the study suggest that the minimum number of lymph nodes harvested in colorectal cancer surgery cannot be set at a fixed value. The lymph node harvest model provides a simple tool to the frontline clinician for comparing standards between multidisciplinary bowel cancer teams. Supported by the National Clinical Audit Support Programme, (NCASP), United Kingdom.     

Mitotic indexes as prognostic predictors in female breast cancer

Summary A series of 688 women with breast cancer were followed-up for a mean of 13 years. Tumour size, axillary lymph node status, histological grade, histological type and two mitotic indexes (M/V; MAI) were assessed and related to disease outcome. Primary tumour size (P<0.0001), the volume-corrected mitotic index (M/V) (P<0.0001), the mitotic activity index (MAI) (P=0.0001), and histological grade (P=0.0074) predicted axillary lymph node status. Recurrence as well as recurrence-free survival was significantly related to the axillary lymph node status (P<0.0001), M/V index (P<0.0001), MAI (P<0.0001), tumour size (P=0.0031) and histological grade (P=0.0208). Multivariate analyses disclosed the tumour size and M/V index as independent predictors of axillary metastasis at diagnosis. Recurrence was related independently to M/V index, axillary metastasis and tumour size. Independent predictors of recurrence-free survival in Cox's analysis were M/V index and axillary lymph node status. Axillary lymph node status (P<0.0001), tumour size (P<0.0001), M/V index (P<0.0001), MAI (P<0.0001) and histological grade (P=0.0009) predicted survical in that order. Cox's analysis showed that axillary lymph node status was the most important independent predictor of survival followed by tumour size and M/V index. In a separate Cox's analysis of axillary-lymph-node-negative patients the M/V index and tumour size were independently related to survival. In conclusion the M/V index is an important prognostic factor in breast cancer and also in axillary-lymph-node-negative breast tumours.Abbreviations MAI mitotic activity index - M/V index volume-corrected mitotic index     

Local and systemic recurrence patterns of urothelial cancer after radical cystectomy

The aim of this study was to evaluate the local recurrence and distant metastasis rates for urothelial carcinoma of the bladder after radical cystectomy and to identify the predictive factors for local recurrence and distant metastasis. The study population was 347 consecutive patients treated with radical cystectomy for urothelial carcinoma of the bladder at our institution. Local recurrence, distant metastasis, and both local and distant recurrence rates were 49 (14.1%) months, 96 (27.7%) months, and 17 (4.9%) months, respectively. The mean follow-up times to recurrence were 14.37 ± 13.25 months (range, 2–60 months) and 14.43 ± 15.72 months (range, 2–109 months) for local recurrence and distant metastasis, respectively (p = 0.808). The mean post-recurrence disease-specific survival (PRDSS) times for local, distant, and both local and distant recurrences were 17.82 ± 3.18 months, 4.16 ± 0.39 months, and 11.41 ± 2.73 months, respectively (p < 0.001). The predictive factors for local recurrence and distant metastasis were stage and nodal involvement (p < 0.001). Sex, grade, lymphovascular invasion (LVI), carcinoma in situ (CIS), and lymph node density (LND; 10% cut-off value) were not predictors for recurrence in the results of the multivariate analysis. The current study demonstrated that stage and pathological nodal involvement were independent predictors of local recurrence and distant metastasis. The results of this study suggest that the early diagnosis and intervention of invasive bladder cancer cases may decrease the number of high stage and lymph node positive cases that have a high risk of local and distant recurrences. The adjuvant treatment options in the presence of risk factors for recurrence may improve survival outcomes.     

Recurrence after surgical resection of intrahepatic cholangiocarcinoma

We aimed to assess the patterns of recurrence after surgery for intrahepatic cholangiocarcinoma (ICC) and the outcomes of treatment in patients with recurrence. From 1981 to 1999, 123 patients with ICC underwent hepatectomy. The 3-year and 5-year survival rates were significantly higher in patients after curative resection (n = 56; 53%, 50%) than in patients after noncurative resection (n = 67; 7%, 2%; P < 0.0001). In 54 patients followed-up after curative resection, the rate of recurrence after surgery was 46%. The recurrences were in the liver (56%), abdomen (disseminated; 24%), and lymph nodes (20%). The rates of recurrence were significantly higher in patients with various classifications of mass-forming ICC tumors (P = 0.039) than in those with other types of tumors, and in patients with tumors over 3 cm in greatest diameter than in those with tumors 3 cm or less (P = 0.006). Hepatic recurrence, abdominal dissemination, and intraductal recurrence were significantly related to tumors that included mass-forming ICC (P = 0.002), tumors that included periductal infiltrating ICC (P = 0.009), and tumors that included intraductal growth ICC (P = 0.038), respectively. Seven patients with recurrence underwent radiation, chemotherapy, immunotherapy, or surgical resection. Only 2 patients, with intrahepatic metastasis and intraductal recurrence, respectively, had good outcomes after surgery. The effectiveness of other treatments has not been established.     

Evaluation of Prognosis for Malignant Rectal Gastrointestinal Stromal Tumor by Clinical Parameters and Immunohistochemical Staining

PURPOSE The aim of this study was to identify associated prognostic factors influencing the outcome of curative resection of rectal gastrointestinal stromal tumor.PATIENTS AND METHODS Diagnostic immunohistochemical staining with CD34, CD117, S-100, desmin, and muscle-specific actin was performed in 46 consecutive patients with previously diagnosed rectal leiomyosarcoma who underwent curative resection from 1979 to 1999. CD44, Bcl-2, P53, and Ki-67 staining were performed on tumors rediagnosed as gastrointestinal stromal tumor for the prognostic evaluation.RESULTS There were 42 (91.3 percent) patients with rectal gastrointestinal stromal tumor (18 females and 24 males; mean age, 58.4 years). Twenty-nine patients underwent radical surgical resections, such as abdominoperineal resection or low anterior resection, whereas the other 13 patients underwent wide local excision, such as transrectal excision or Kraskes operation. Sixteen tumors were classified as high-grade gastrointestinal stromal tumors, and 26 as low-grade. No tumor had a positive P53 stain. Twenty-seven patients (64.3 percent) developed recurrence or metastasis postoperatively (median follow-up, 52 months). The one-year, two-year, and five-year disease-free survival rates were 90.2 percent, 76.7 percent, and 43.9 percent, respectively. Of these patients with recurrence, subsequent resections in 12 patients with local recurrence, transarterial tumor embolism or STI-571 chemotherapies in 3 patients with distant mestastases were performed. The one-year, two-year, and five-year overall survival rates were 97.4 percent, 94.3 percent, and 83.7 percent, respectively. Bcl-2 (P = 0.007) and histologic grade (P = 0.05) in disease-free survival analysis and age <50 years (P = 0.03) and tumor size >5 cm (P = 0.02) in overall survival analysis were independent prognostic factors. The group with wide local excision had a higher local recurrence rate than that of the radical resection group (77 percent vs. 31 percent, P = 0.006), despite smaller tumors (4.5 vs. 7.2 cm, P = 0.05). There was no difference in the incidence of distant metastasis between the two groups.CONCLUSION Younger age (<50 years), higher histologic tumor grade, positive Bcl-2 status, and larger tumors (>5 cm) were factors associated with significantly poorer prognoses for rectal gastrointestinal stromal tumor. Radical resection was superior to wide local excision in the prevention of local recurrence, but not that of distant metastases.     

Salvage surgery after definitive chemoradiotherapy for esophageal cancer

Background Definitive chemoradiotherapy has been performed as a first-line treatment for esophageal cancer, whereas salvage surgery might be the only reliable treatment for patients with recurrence after definitive chemoradiotherapy.Methods We reviewed 38 patients with squamous cell carcinoma who underwent esophagectomy and 6 patients who underwent lymphadenectomy after definitive chemoradiotherapy (≥50 Gy).Results The median survival time and 5-year survival rate after salvage esophagectomy were 16 months and 27%, respectively. Three of the 7 patients who had cervical esophageal cancer underwent cervical esophagectomy with laryngeal preservation. Two patients (5.2%) who underwent salvage esophagectomy with three-field lymphadenectomy before 1997 died of postoperative complications, but no patient died of complications thereafter. Although the overall survival after salvage esophagectomy was correlated with residual tumor (R) (P = 0.0097), the median survival time of 7 patients with residual tumors (R₂) was 7 months. Overall postoperative survival was closely correlated with the response to chemoradiotherapy (P < 0.0001) but was not associated with histologic effects on resected specimens. Survival was significantly correlated with the depth of viable tumor invasion (pT) (P = 0.0013) and with lymph node metastasis (pN) (P < 0.0001). Long-term survival was achieved in 5 of the 6 patients who underwent salvage lymphadenectomy.Conclusions Salvage surgery should be considered for patients with recurrence after definitive chemoradiotherapy. Salvage lymphadenectomy may be useful for recurrence confined to the lymph nodes whereas postoperative complications of salvage esophagectomy should be warranted.     

Results of treatment of distal rectal carcinoma since the introduction of total mesorectal excision: a single unit experience, 1994–2003

Background and aims This study reviewed the results of surgery for distal rectal cancer (where the tumour was within 6 cm of the anal verge) following the introduction of total mesorectal excision for rectal cancer in one institution.Patients and methods One hundred and fifty-three patients who had undergone elective curative surgical resection of rectal cancer within 6 cm of the anal verge were included. The demographic, operative and follow-up data were collected retrospectively. Comparisons were made between patients who had different surgical procedures.Results The overall operative mortality rate was nil, and the morbidity 41%. With a mean follow-up of 37 months (range 5–100 months), local recurrence occurred in 18 of the patients. The 5-year actuarial local recurrence rates for double-stapled anastomosis, low-strength anastomosis and abdominoperineal resection (APR) were 39, 17 and 11% respectively. The local recurrence rate was significantly higher for double-stapled low anterior resection than for the other types of operation (P=0.007). On multivariate analysis type of surgery (P=0.025) and tumour stage (P=0.043), were associated with local recurrence, but only stage was a significant prognosticator of overall survival (P=0.0006).Conclusion With the practice of total mesorectal excision, APR was still necessary in 40% of patients with rectal cancer within 6 cm of the anal verge. The local recurrence rate was lower in patients treated with APR than in those with double-stapled low anterior resection; however, survival rates were similar in these two groups.     

Surgical outcome after curative resection of rectal leiomyosarcoma

PURPOSE: The aim of this study is to present the prognosis and possible associated prognostic factors after curative resection of rectal leiomyosarcoma. METHODS: From 1979 to 1996 our hospital saw 40 patients with rectal leiomyosarcoma, including 19 females, who did not have metastasis initially and received curative resection and regular postoperative follow-up. RESULTS: The mean age of the 40 patients was 58.7 years. Anal bleeding and perianal pain were the two most common symptoms at initial diagnosis. Twenty-nine patients received a radical surgical resection, such as abdominoperineal resection or low anterior resection; the other 11 patients received a wide local excision, such as transrectal excision or Kraske's operation. Sixteen tumors were classified as high-grade leiomyosarcoma, and 23 as low grade. Nineteen patients (48 percent) developed recurrence or metastasis postoperatively (median follow-up, 35 months). The overall and disease-free (1-year, 3-year, and 5-year) survival rates were 97, 90, and 75 percent and 90, 59, and 46 percent, respectively. In univariate analysis, younger group (<50 years, n=9,P=0.033) and high-grade leiomyosarcoma (P=0.043) showed poorer prognosis in the disease-free survival curve. In the multivariate Cox model, gender, tumor size, tumor location, and operation type did not significantly affect disease-free survival, whereas histologic grade (P=0.037) and age divided by a level of 50 years (P=0.009) were shown to be independent factors. There was a strong trend toward higher local recurrence rate for the wide local excision group than for the radical resection group (55vs. 24 percent,P=0.067) despite the wide local excision group being composed of smaller tumors (5.1vs. 7.5 cm,P=0.069). There was no difference in the incidence of distant metastasis between the two groups with different operation types. The metastasis rates of the wide local excision and radical resection groups were 27 and 38 percent, respectively. CONCLUSION: A younger age (<50 years) and a high histologic grade of tumor were the two most significant poor prognostic factors for rectal leiomyosarcoma. Radical resection may be superior to wide local excision in the prevention of local recurrence but not distant metastasis.     

Absence of Lymph Nodes in the Resected Specimen After Radical Surgery for Distal Rectal Cancer and Neoadjuvant Chemoradiation Therapy: What does it Mean?

Purpose The number of retrieved lymph nodes during radical surgery has been considered of great importance to ensure adequate staging and radical resection. However, this finding may not be applicable after neoadjuvant therapy in which, not only is there a decrease in lymph nodes recovered, but also a subgroup of patients with absence of lymph nodes in the resected specimen. Methods Patients with absence of lymph nodes were compared with patients with ypN0 disease and patients with ypN+ disease. Results Thirty-two patients (11 percent) had absence of lymph nodes, 171 patients (61 percent) had ypN0 disease, and 78 patients (28 percent) had ypN+ disease. Patients with absence of lymph nodes had significantly lower ypT status (ypT0-1, 40 vs. 13 percent; P < 0.001) and decreased risk of perineural invasion (6 vs. 21 percent; P = 0.04) compared with ypN0 patients. Five-year disease-free survival (74 percent) was similar to patients with ypN0 (59 percent; P = 0.2), and both were significantly better than patients with ypN+ disease (30 percent; P < 0.001). Conclusions Absence of lymph nodes retrieved from the resected specimen is associated with favorable pathologic features (ypT and perineural invasion status) and good disease-free survival rates. In this setting, absence of retrieved lymph nodes may reflect improved response to neoadjuvant chemoradiation therapy rather than inappropriate or suboptimal oncologic radicality. Presented at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 6, 2007.     

Bacterial Translocation May Influence the Long-Term Survival in Colorectal Cancer Patients

Purpose The purpose of this study was to investigate the association of bacterial translocation with long-term disease-specific and disease-free survival in colorectal cancer patients. Methods This was a prospective cohort study in which 128 and 30 colorectal cancer patients undergoing curative and palliative resections, respectively, were recruited between 1992 and 1997. Samples of mesenteric lymph nodes were harvested for culture before administration of prophylactic antibiotics. Median follow-up for patients without cancer death was 103 (range, 72–147) months. This cohort of patients was internally validated by Dukes staging. Results The cumulative disease-specific survival (time to death) and disease-free survival (time to recurrence) for all patients at five years of follow-up was 55 percent (standard error [SE], 4.4 percent) and 65 percent (SE, 4.8 percent), respectively. Bacteria were isolated from the mesenteric nodes of 23 (15 percent) patients. There was no association between bacterial translocation and nodal metastases, bowel obstruction, and septic complications. Patients with confirmed bacterial translocation had a worse disease-specific survival (n=158, 5-year survivorship estimates±SE, 38 percent±12 percent vs. 58 percent±4.7 percent; P < 0.01) and disease-free survival (n=128, 5-year survivorship estimates±SE, 46 percent±14 percent vs. 66 percent±5 percent; P = 0.004) than those without. Using multivariate Cox regression analysis, bacterial translocation was a predictor of disease-specific survival (P = 0.011) and disease-free survival (P = 0.02) independent of other pathologic prognostic indicators. Conclusion Colorectal cancer patients with bacterial translocation in the mesenteric lymph nodes have a worse outcome. Presented at the meeting of the Society of Academic and Research Surgery, Belfast, Northern Ireland, January 14 to 16, 2004.     

Clinical characteristics of initial recurrence in lung after surgical resection for pancreatic ductal adenocarcinoma

BackgroundThe clinical characteristic differences at the initial recurrence site after resection for pancreatic ductal adenocarcinoma (PDAC) remain unknown. We investigated the clinical characteristics in patients with lung recurrence after surgical resection and evaluated the outcome of resection for isolated lung recurrence.MethodsOf 442 consecutive PDAC patients who underwent surgical resection between 2002 and 2018, 229 had recurrence on imaging. Initial recurrence sites were the liver, lung, local, peritoneal, multiple organs, and others. We analyzed the clinicopathologic factors and outcomes, comparing by initial recurrence site, and investigated the outcomes of resection for isolated lung recurrence.ResultsLiver recurrences were the most frequent (n = 60, 26%), followed by lung recurrence (n = 48, 21%). The interval from surgery to recurrence was significantly longer in lung recurrence (P = 0.0001). Patients with lung recurrence had significantly longer overall survival after diagnosis (P < 0.0001). Patients who underwent surgical resection of lung recurrence had a significantly prolonged overall survival rate after recurrence diagnosis (P = 0.004).ConclusionsPatients with lung recurrence had significantly prolonged survival than those with other recurrence patterns. Resection for isolated lung recurrence represented relatively good prognosis, and possibly may be beneficial in highly-selected patients.