Postoperative morbidity and mortality after induction chemoradiotherapy for locally advanced lung cancer: an analysis of 350 operated patients.

OBJECTIVE: The purpose of this study was to evaluate the frequency and risk of postoperative cardiopulmonary and bronchial complications in patients with locally advanced lung cancer after induction chemoradiotherapy and definitive surgery. METHODS: We reviewed the charts of 350 patients who underwent thoracotomy in the course of two phase II and one phase III studies with preoperative chemotherapy (three cycles of split- dose cisplatin/etoposide in 261 patients and cisplatin/paclitaxel in 89 patients) followed in all 350 patients by concurrent chemoradiotherapy (one cycle cisplatin/etoposide combined with 45 Gy hyperfractionated accelerated radiotherapy) and operation from March 1991 to December 2000. Univariate and multivariate analysis was used to identify predictors of complications. RESULTS: Of 350 consecutive patients 278 (79%) had a non-small cell lung cancer (154 stage IIIA and 124 IIIB) and 72 (21%) a small cell lung cancer (12 stage IIA/B, 35 stage IIIA and 25 stage IIIB). Resections included 125 pneumonectomies (35%), 15 bilobectomies (4.3%), 37 sleeve lobectomies (11%), 157 lobectomies (45%), and two segmentectomies (0.6%); 14 patients (4%) had an exploration only. Additionally to pulmonary resection 32 patients underwent a partial chest wall resection. One hundred and fifty-four patients (44%) developed early or late complications; the hospital mortality rate was 4.9% (17 patients). The causes of death were sepsis (n=5), pneumonia and respiratory failure (n=4), adult respiratory distress syndrome (n=3), cardiac failure (n=3) and lung embolism (n=2). Multivariate analysis extracted increased age, lower Karnofsky status, abnormal echocardiographic findings and no bronchial stump covering technique to be risk factors for perioperative morbidity. Lower Karnofsky status and increased age were significant risk factors for postoperative mortality. CONCLUSION: This retrospective analysis demonstrates that in patients with locally advanced lung cancer and induction chemoradiotherapy, surgery can be feasible with acceptable mortality but increased morbidity. Accurate cardiopulmonary evaluation before surgery and standard operative techniques with protection of bronchial stump or anastomosis can contribute to a reduced complication rate with this intensive approach.     

Operative complications and early mortality after induction therapy for lung cancer.

OBJECTIVE: Induction therapy for advanced lung cancer allows improvement of completeness of resection and survival. However, predictive risk factors for postoperative complications and early mortality remain controversial. We report our 14-year experience with this combined approach. METHODS: One hundred and thirty-nine patients (100 males and 39 females) underwent induction therapy and surgery for stage IIIA and B lung cancer. The mean age was 58.4+/-7.7 years. We retrospectively collected demographic data, preoperative functional parameters, type of operation, associated disorders, staging, induction regimen (chemotherapy alone or associated with radiotherapy). Univariate and multivariate analyses were performed to identify predictors of postoperative complications and early mortality. RESULTS: One hundred and nine patients received chemotherapy (mainly based on cisplatin and gemcitabine) and 30 received chemoradiotherapy (median dose 50Gy). Complications developed in 49 patients (35%). The most frequent was persistent air leakage (23-30% of the lobectomies), followed by cardiac complications, respiratory failure, and infections. Five patients (3.5%) died in the postoperative period and four of them had received pneumonectomy (mortality for pneumonectomy: 12.5%). The statistical analysis demonstrated that only pneumonectomy was associated with an increased mortality risk with no differences between intra- and extrapericardial dissection or right and left pneumonectomy. CONCLUSIONS: Induction therapy seems to be associated with an increased incidence of air leakage; the risk of other complications is acceptable. Pneumonectomy is associated with an increased risk of mortality and should be performed in selected patients.     

The impact of pre- or postoperative radiochemotherapy on complication following anterior resection with en bloc excision of female genitalia for T4 rectal cancer

Objective  The aim of the study was to assess the mortality and morbidity following extended anterior resection with excision of internal female genitalia combined with pre- or postoperative chemoradiotherapy in women with extensive rectal cancer.
Method  The study included a consecutive series of 21 women with T4 adenocarcinoma of the rectum infiltrating the reproductive organs treated with curative intent between 1997 and 2003. All patients had an extended anterior sphincter preserving resection of the rectum (total mesorectal excision) and hysterectomy with or without posterior vaginal wall excision. In all patients, surgery was combined with adjuvant radiochemotherapy. Ten patients received preoperative radiotherapy (50.4 Gy) concurrently with two courses of chemotherapy [fluorouracil with folinic acid (FA)] followed by surgery within 6–8 weeks and subsequently four courses of postoperative chemotherapy. Eleven received postoperative chemoradiotherapy (50.4 Gy plus fluorouracil with FA).
Results  There was no postoperative mortality. Postoperative complications were observed in 57% patients (early in 14% and late in 52%). These included: anterior resection syndrome with anorectal dysfunction in 52% (requiring proximal diversion in 5%), urinary complications in 24% (complete incontinence requiring a permanent catheter in 5%). In addition, postoperative acute bleeding requiring relaparotomy, delayed wound healing caused by superficial infection, anastomotic leakage, prolonged bowel paralysis, benign rectovaginal fistula and anastomotic stricture occurred (5% each). The risk of postoperative morbidity (52%) was similar for patients with or without preoperative radiochemotherapy.
Conclusion  Despite this aggressive therapeutic approach, most postoperative complications were transient or could be treated. Preoperative radiochemotherapy did not increase the risk of morbidity.     

Primary lung cancer surgery after curative chemoradiotherapy for esophageal cancer patients

The safety and perioperative problems of primary lung cancer surgery after curative chemoradiotherapy (CRT) for thoracic esophageal cancer (EC) are controversial. We retrospectively evaluated six patients who had received curative CRT for EC from 2003 to 2009, in whom the lung nodule was identified as a primary lung cancer and who subsequently underwent pulmonary resection. The treatment for EC consisted of chemotherapy with cisplatin and 5-fluorouracil with concurrent curative thoracic radiotherapy (60 Gy). The median age at the surgery was 75 years (range 69-80 years). The median time from radiation to pulmonary resection was 26 months (range 7-70 months). All patients had a predicted postoperative forced expiratory volume in 1 s (FEV(1))% of >40% before lung surgery. The surgical difficulty involves mediastinal lymph node dissection following tissue fibrotic changes after thoracic radiation. Postoperative complications occurred in two patients, and included arrhythmia and empyema. The patient who developed empyema had a massive pericardial effusion after CRT and underwent pericardial fenestration at the time of pulmonary resection. There was no operative mortality. Lung cancer surgery after curative CRT for EC is feasible in carefully evaluated and selected patients.     

Postoperative complications in relation with induction therapy for lung cancer.

OBJECTIVES: The purpose of this study was to evaluate the risk of lung cancer surgery following induction chemotherapy and/or radiotherapy. METHODS: This retrospective study included 69 patients treated from January 1990 to January 1998 for a primary lung cancer in whom surgery had been performed after induction treatment. Surgery had not been considered initially for the following reasons: N2 disease (IIIA, n = 25); temporary functional impairment (two stages IB and two stages IIIA (N2), n = 4); and doubtful resectability (stage IIIB (T4), n = 40). The medical regimen resulted in combined radio-chemotherapy in 43 patients who received two to four cycles of chemotherapy (average 2.9 +/- 0.8 cycles) and 43 +/- 8 Gy (range 20--60 Gy), or chemotherapy alone in 26 patients (3 +/- 0.7 cycles). RESULTS: Exploratory thoracotomy was performed in four patients (6%). The in-hospital mortality was 9% (n = 6) from respiratory origin in all cases. There were four re-operations (6%): three for bronchial fistula and one for bleeding. Thirty-five patients (51%) required blood transfusion (4.5 +/- 3.8 cell packs). The incidence of early and delayed bronchial fistula after pneumonectomy was 15%. Thirteen patients had a postoperative pneumonia (19%). CONCLUSIONS: Surgery for lung cancer after induction chemotherapy and/or radiotherapy is associated with an increased risk. If the mortality seems 'acceptable', the morbidity rate, however, is high.     

Effect of preoperative chemotherapy for bulky N2 non-small-cell lung cancer]

The effect of chemotherapy as the adjuvant therapy to bulky N2 disease (stage IIIA) non-small-cell lung cancer was examined. From January 1992 to December 1996, 464 patients with non-small-cell lung cancer underwent surgery. Seven patients (1.5%) with N2 disease (stage IIIA) received two cycles of preresectional cisplatin and vindesin chemotherapy, followed by standardized surgical resection (Group A). 46 patients (9.9%) had pathological N2 disease (T1-3, M0) after surgery (Group B). In Group A a complete resection was accomplished in two patients (28.6%), and five patients had incomplete resection with a deseased margin, followed thoracic irradiation 60 to 75 Gy. In three patients in Group A the N2 disease was pathologically downstaged to N1 or N0 disease. Overall survival at five years in Group A and in Group B was 48% and 39%, and median survival time was 49 months and 38 months. Although complete resection rate was lower in Group A (28.6%) than in Group B (78.2%), there was no significant difference between five year survival and median survival time in Group A and Group B. These data may be thought to suggest that induction chemotherapy in Group A was effective on occult micrometastatic disease.     

Survival and postoperative complications after extended surgery for non-small-cell lung cancer. A retrospective study.

OBJECTIVE: We evaluated survival after extended surgery in patients with non-small-cell lung cancer and the effects of induction therapy on results and complications. SUBJECTS AND METHODS: Between April 1987 and March 1998, 127 patients with pathological T3 (pT3) or T4 (pT4) non-small-cell lung cancer underwent extended surgery combined with resection of neighboring organs. Of these, 35 received induction therapy. In the remaining 92, surgery preceded other therapy. Long-term results and postoperative respiratory complications were analyzed and compared between the patients with and without induction therapy. RESULTS: Overall 5-year survival after extended surgery was 37%. Five-year survival rates in the pT3 was 41% and that in the pT4 group 28% (p = 0.030). Five-year survival rate in the pN0-1 was 46% and that in the pN2-3 group 26% (p = 0.003). No significant difference was observed in survival curves between patients with and without induction therapy. Induction therapy responders showed better survival than nonresponders. To prevent postoperative fatal complications due to bronchopleural fistula, we prophylactically covered the bronchial stump using autologous tissue in 31 induction therapy patients, and no mortality due to complications was seen in this group. CONCLUSION: Long-term survival after extended surgery was observed in pT3 and pT4 patients, especially among those with a pN0-1 status. Induction therapy responders may be considered good candidates for extended surgery because of the favorable prognosis in contrast to that for nonresponders.     

Survival and postoperative complications after extended surgery for non-small-cell lung cancer

Objective: We evaluated survival after extended surgery in patients with non-small-cell lung cancer and the effects of induction therapy on results and complications.Subjects and Methods: Between April 1987 and March 1998, 127 patients with pathological T3 (pT3) or T4 (pT4) non-small-cell lung cancer underwent extended surgery combined with resection of neighboring organs. Of these, 35 received induction therapy. In the remaining 92, surgery preceded other therapy. Long-term results and postoperative respiratory complications were analyzed and compared between the patients with and without induction therapy.Results: Overall 5-year survival after extended surgery was 37%. Five-year survival rates in the pT3 was 41% and that in the pT4 group 28% (p = 0.030). Five-year survivalrate in the pNO-1 was 46% and that in the pN2-3 group 26% (p = 0.003). No significant difference was observed in survival curves between patients with and without induction therapy. Induction therapy responders showed better survival than nonresponders. To prevent postoperative fatal complications due to bronchopleural fistula, we prophylactically covered the bronchial stump using autologous tissue in 31 induction therapy patients, and no mortality due to complications was seen in this group.Conclusion: Long-term survival after extended surgery was observed in pT3 and pT4 patients, especially among those with a pN0-l status. Induction therapy responders may be considered good candidates for extended surgery because of the favorable prognosis in contrast to that for nonresponders.     

Postoperative complications of lung resection after induction chemotherapy using Paclitaxel (and radiotherapy) for advanced non-small lung cancer

BACKGROUND: Locally advanced non-small-cell lung carcinoma is currently treated by multidisciplinary protocols using a combination of chemotherapy, radiotherapy and surgery. However the best strategy for applying these therapeutic measures has not yet been established. One of the difficulties of using these forms of treatment is their toxicity. Our aim was to determine whether the postoperative course of the disease can be influenced by preoperative chemotherapy in any way. METHODS: Nineteen patients were surgically treated after receiving induction treatment between October 1996 and October 1998. The indications for giving induction treatment were: stage III disease in 12 patients (1 Pancoast tumor), lung cancer and solitary brain metastasis in 4 patients, double primary lung cancer in 3 patients (1 synchronous and 2 metachronous). Variables were the chemotherapy treatment time interval from the beginning to surgery, the type of surgery, postoperative mortality and morbidity. Mean age was 55.9 years old (range between 25 and 70 years). Predominant gender was male (18 men and 1 woman). Neoadjuvant treatment consisted of chemotherapy in all patients (Paclitaxel, Cysplatin and Vinorelbine in cycles for a mean period of 3 months), and radiotherapy (14 patients). Pulmonary resections were: pneumonectomy (2 patients), lobectomy (16 patients) and wedge resection (1 patient). There were no exploratory thoracotomies. Bronchoplasty procedures were necessary in 5 cases and angioplasty in 5. Cardiopulmonary bypass was necessary in 1 case in order to resect an infiltrated pulmonary vein. Intraoperative radiotherapy (IORT) was used in 9 cases. RESULTS: Complications occurred in the immediate postoperative period in 9 patients: 1 postpneumonectomy respiratory distress syndrome, 2 bronchopleural fistulae, 4 prolonged air leaks, 1 complete dehiscence of the thoracotomy scar and 1 colitis caused by anaerobes. The postoperative mortality (within 30 days) was 2 patients (10.5%): 1 died from bronchopleural fistula and the other from postpneumonectomy respiratory distress syndrome. However, if we take into account the fact that the case of anaerobic colitis also ended with the patient's death on the 48th postoperative day, and we include it in the mortality rate, the final mortality is higher (15.8%). CONCLUSIONS: Surgery for non-small-cell lung carcinoma has to be considered a high-risk procedure. But, if patients are selected appropriately and the perioperative management is satisfactory, reasonable rates of morbidity and mortality can be achieved. More studies are needed in order to define the exact role of these therapeutic measures.     

Pulmonary resection after curative intent radiotherapy (>59 Gy) and concurrent chemotherapy in non-small-cell lung cancer

Background

Pulmonary resection after chemotherapy and concurrent full-dose radiotherapy (>59 Gy) has previously been associated with unacceptably high morbidity and mortality. Subsequently neoadjuvant therapy protocols have used reduced and potentially suboptimal radiotherapy doses of 45 Gy. We report a series of 40 patients with locally advanced non-small-cell lung cancer who successfully underwent pulmonary resection after receiving greater than 59 Gy radiation and concurrent chemotherapy. Operative results and midterm survival follow-up are presented.

Methods

Data were reviewed from 40 consecutive patients who underwent lung resection after receiving high-dose radiotherapy and concurrent platinum-based chemotherapy between January 1994 and May 2000. The follow-up closing interval for this study was until August 2003 or time of death.

Results

Preoperative stage was IIb (7 patients), IIIA (21 patients), IIIB (10 patients), and IV (2 patients with isolated brain metastasis). Thirteen patients exhibited Pancoast tumors. Median time from completion of induction therapy to surgery was 53 days. Twenty-nine lobectomies and 11 pneumonectomies (7 right, 4 left) were performed. There were no postoperative deaths. Intercostal muscle flaps were used prophylactically in all but one pneumonectomy patient. Seven patients required perioperative transfusions. Median intensive care unit (ICU) time averaged 2 days and the total length of stay was 6 days. One patient exhibited postpneumonectomy pulmonary edema and a bronchopleural fistula developed in another patient (not receiving an intercostal muscle flap). Thirty-four of 40 patients (85%; 95% CI: 70%-94%) were downstaged pathologically, 33 out of 40 patients (82.5%, 95% confidence interval [CI]: 67%-93%) indicated no residual lymphadenopathy, and 18 out of 40 patients (45%, 95% CI: 29%-61%) exhibited a complete pathologic response. Median follow-up was 2.8 years. The 1-, 2-, and 5-year overall survival rates were 92.4%, 66.7%, and 46.2%, respectively. Disease-free 1-, 2-, and 5-year survival rates were 73.0%, 67.2%, and 56.4%, respectively. Median disease-free survival has not been reached.

Conclusions

Pulmonary resection may be performed safely after curative intent concurrent chemotherapy and radiotherapy to greater than 59 Gy. High pathologic complete response rates and sterilization of mediastinal lymph nodes were observed accompanied by highly favorable survival rates. This experience, though promising, will require confirmation in a prospective multiinstitutional clinical trial.     

Whole-lung radiotherapy for giant cell tumors of bone with pulmonary metastases

Three patients initially diagnosed with benign giant cell tumors of bone who had lung metastases develop were treated with whole-lung radiotherapy as part of the therapeutic treatment of their distant disease. External beam therapy to 16 Gy in 10 fractions was delivered to the whole lung, with a boost of 35 to 45 Gy to sites of gross metastatic disease. One patient's lung metastases progressed after treatment, and the patient soon died. The two other patients were long-term survivors (7.5 years and 13 years) with complete resolution of detectable disease. One of the two patients required two additional courses of local radiation to metastatic sites. The authors therefore recommend whole lung radiotherapy to 16 Gy with an additional boost to 35 to 45 Gy to gross disease as an option for patients with pulmonary metastases who are poor surgical candidates, who refuse thoracic surgery, whose disease is technically unresectable, or whose disease recurs or progresses after surgery or chemotherapy.     

直肠癌术后局部复发综合治疗的疗效分析

目的：分析直肠癌根治术后局部复发的类型、综合治疗的疗效及预后。方法：对直肠癌术后局部复发、以往未接受过放疗的66例病人进行疗效分析。原手术方式为经腹直肠切除术45例(Dixon术40例，Parks术5例)，腹会阴直肠切除术21例。经腹直肠切除术后复发以吻合口为主(37／45，82．2％)，腹会阴直肠切除术后复发则以盆腔或会阴为主(19／21，90．5％)。复发后盆腔放疗中位剂量为40(20—64）Gy，临床症状缓解中位剂量26(10～52)Gy。其中26例在放疗过程中或之后接受过中位7个(2～12)疗程以5-FU为主的化疗。有22例放疗后获补救手术机会。结果：全组中位生存期24个月。Kaplan-Merier法计算生存率，放疗后1、3年总生存率分别为72．2％、17．9％。单因素分析并Log rank检验生存率差异，显示生存率与原发病变的期别、术后复发时间、复发部位及是否加用化疗无关，而仅与是否再次行补救手术有关。放疗后加用补救手术者3年生存期明显较长，为36．0％比8．8％(P=0．016)。结论：直肠癌根治术后局部复发者，放疗具有良好的姑息减症的作用；对部分经腹直肠切除术后的复发病例，放射治疗加补救手术能明显延长生存期。     

Analysis of Early Postoperative Morbidity Among Patients with Rectal Cancer Treated with and without Neoadjuvant Chemoradiotherapy

Background The impact of neoadjuvant treatment and their subsequent early complications in the treatment of rectal cancer has not been adequately assessed. The aim of this prospective study was to evaluate early postoperative morbidity and mortality among patients with rectal cancer treated with adjuvant radiotherapy and chemotherapy followed by surgery, compared with patients treated with surgery alone. We also identified independent risk factors associated with early major complications. Methods Between 1995 and 2004, 273 consecutive patients underwent treatment for rectal cancer. A total of 170 patients (group A) received preoperative radiotherapy with a total of 45–50.4 Gy (180 cGy per day) and 5-fluorouracil-based chemotherapy, followed by surgery; 103 patients (group B) were treated with surgery alone. Dependent variables related to patients, treatment, radiotherapy, and tumor were analyzed. Results Both groups were similar with regard to age, sex, body mass index, American Society of Anesthesiologists (ASA) score, and tumor location but not for ileostomy (27% in group A vs. 6.8% in group B). The number of complications was similar in both groups (43.1% in group A vs. 44.6% in group B). No differences in wound infection (8.2% vs. 7.8%), intra-abdominal abscess (4.7% vs. 4.9%), anastomotic dehiscence (4.2% vs. 3.8%), postoperative hemorrhage (3.5% vs. 3.9%), urinary complications (6.5% vs. 4.9%), paralytic ileus (8.9% vs. 9.7%), or general complications (7.1% vs. 9.6%) were found. The global mortality in the first 30 days after surgery was .7%. An ASA score of III–IV and surgery duration longer than 3 hours were identified as independent prognostic factors for early complications. Conclusions Preoperative chemoradiation in patients with rectal cancer treated with surgery is not associated with a higher incidence of early postoperative complications. The patient’s preoperative clinical condition and lengthy surgery time are prognostic factors for early complications.     

Combined resection of distal aortic arch for T4N0 non-small-cell lung cancer with aortic arch invasion

Three men age: 39-51 years (mean: 43.3 years) with T4N0 lung cancer infiltrating the distal aortic arch underwent combined resection of the left upper lobe, distal aortic arch, and left subclavian artery using partial extracorponeal circulation. Selective cerebral perfusion was used in 2. One underwent induction therapy (CDDP + VP - 16 x 2 + radiation 30 Gy), and all underwent adjuvant therapy. No postoperative complications or postoperative death occurred. Average ICU stay was 2.3 days. All patients are alive without local recurrence. Two were disease-free 37 and 26 months after surgery, and 1 had adrenal gland metastasis 8 months after surgery. Extended resection of the aortic arch in lung cancer is thus feasible and worthwhile in patients with T4N0 non-small-cell lung cancer.     

Postoperative radiotherapy for locally advanced colon cancer

Background: The role of adjuvant postoperative radiotherapy for locally advanced colon cancer is not well documented. Methods: Seventy-eight patients who underwent a complete resection of B2-C colon cancer received postoperative radiotherapy. Twenty-eight patients received ⩽45 Gy; 50 patients received 50–55 Gy. Twenty-seven patients received adjuvant fluorouracil-based chemotherapy. All patients were followed for a minimum of 3 years; no patients were lost to follow-up. Results: The overall local control rate was 88%. The 5-year actuarial rate of local control was 96% after 50–55 Gy postoperative radiotherapy compared with 76% after <50 Gy (p=0.0095). Multivariate analysis of local control showed that only radiotherapy dose significantly influenced this end point. Cause-specific survival rates at 5 years were B2, 67%; B3, 90%; C1, 100%; C2, 61%; C3, 36%; and overall, 63%. Multivariate analysis of cause-specific survival showed that only stage significantly influenced this end point. Bowel obstruction caused by adhesions developed in three patients and required a laparotomy; radiation-induced sarcoma developed in one additional patient. Conclusions: Postoperative radiotherapy appears to reduce the risk of local recurrence in patients with locally advanced colon cancer. The optimal dose is probably 50–55 Gy at 1.8 Gy per fraction. Postoperative radiotherapy may improve cause-specific survival for patients with stages B3 and C2 cancers.     

Safe pulmonary resection after chemotherapy and high-dose thoracic radiation.

BACKGROUND: Pulmonary resection after high-dose thoracic irradiation is reported to be associated with a high morbidity and mortality, and has been considered to be prohibitive. METHODS: We report safe pulmonary resection in 19 consecutive patients receiving neoadjuvant therapy that included greater than 59 Gy thoracic radiation. The mean thoracic radiation dose was 61.8 Gy (range 59.5-66.5) and mean age was 52 years (range 36-72 years). Cell type was adenocarcinoma (6), squamous (7), and other non-small cell lung cancer (NSCLC) (6). Sixteen of 19 patients received concurrent chemotherapy. Median time from end of treatment to surgical resection was 89 days (range 22-258 days). Surgical resection included 13 lobectomies and six pneumonectomies (four right, two left). RESULTS: A complete pathologic response was seen in 8 of 19 (42%) patients. Three patients required intraoperative transfusion of blood. Mean intensive care unit stay was 2.0 days (range 1-8 days), and mean length of stay (LOS) was 8.0 days (range 3-18 days). There were four postoperative complications; one bronchopulmonary fistula, one subarachnoid-pleural fistula, and 2 patients with prolonged atelectasis. There was no incidence of acute respiratory distress syndrome (ARDS) or operative mortality. CONCLUSIONS: Pulmonary resection, including pneumonectomy, after chemotherapy and high-dose thoracic radiation may be performed safely with a low rate of intraoperative and postoperative complications.     

B003Electrical Stimulation of the S3 Sacral Root Increased the Frequency of Both Colonic High Amplitude Propagating Pressure Waves and Defaecation in Patients with Slow Transit Constipation

Objective  This randomized study compared two neoadjuvant treatments in patients with a low rectal cancer less than 2 cm from the anal verge that would have required APR before radiotherapy.
Method  A total of 207 patients (71% uT3) with a rectal carcinoma at 0.5 cm from the anal verge were randomized in two groups. The group HDR received a high dose of radiotherapy (45 Gy + boost 18 Gy). The group RCT received 45 Gy with concomitant chemotherapy (5FU). Surgery was performed 6 weeks after treatment, surgeons were trained with TME, APR and intersphincteric resection.
Results  The rate of sphincter preserving surgery was 83% after HDR and 86% after RCT ( P  = 0.69). There was no difference in morbidity, clinical tumour regression (80% vs. 87%) and complete pathological response (8% vs. 15%) between HDR and RCT. Overall, the rate of R0 resection was 78%. After a follow-up of 23 months, the rates of local and distant recurrence were 6% and 19% respectively and the disease-free survival was 77%. Survival was better after sphincter preservation than after APR.
Conclusion  Sphincter preservation was achieved in 85% of ultra-low rectal carcinomas without compromising oncological prinicples. No difference was observed between HDR and RCT. Further follow-up is necessary to confirm this conservative approach.     

Analysis of postoperative complications after esophagectomy for esophageal cancer in patients receiving neoadjuvant therapy

Postoperative complications were investigated in 72 patients who received neoadjuvant therapy with esophagectomy. Preoperative chemotherapy consisted of 5-fluorouracil (700 mg/m2/day, on days 1 to 5), cisplatinum (70 mg/m2/day, on day 1), and leucovorin (20 mg/m2/day, on days 1 to 5). Preoperative chemoradiotherapy consisted of cisplatinum combined chemotherapy and radiotherapy (total dosage of 30–70 Gy). The incidence of postoperative pneumonia (16%) and anastomotic leakage (24%) in the preoperative chemotherapy group was slightly higher than that in the control group (n = 506), and mortality (6.0%) after esophagectomy in the preoperative chemotherapy group was higher than that (2.4%) of the control group. Postoperative morbidity and mortality were observed more frequently in patients who received two cycles of the chemotherapy than those receiving only one cycle. Postoperative complications occurred more frequently in patients suffering high grade toxicities due to the preoperative chemotherapy. The highest preoperative serum creatinine value correlated to that of postoperative period (r = 0.6494). The use of the preoperative chemoradiotherapy with a total exposure dosage of 60 Gy or more significantly increased the postoperative pneumonia rate (67%; p < 0.05) compared to the group receiving 40 Gy or less. The mortality rate (33%) also increased. The second cycle of the preoperative chemotherapy should be cancelled if patients suffer high grade toxicities during or after the first cycle, and the total exposure dosage of the preoperative chemoradio-therapy should be limited to 40 Gy or less.     

Analysis of postoperative complications after esophagectomy for esophageal cancer in patients receiving neoadjuvant therapy.

Postoperative complications were investigated in 72 patients who received neoadjuvant therapy with esophagectomy. Preoperative chemotherapy consisted of 5-fluorouracil (700 mg/m2/day, on days 1 to 5), cisplatinum (70 mg/m2/day, on day 1) and leucovorin (20 mg/m2/day, on days 1 to 5). Preoperative chemoradiotherapy consisted of cisplatinum combined chemotherapy and radiotherapy (total dosage of 30-70 Gy). The incidence of postoperative pneumonia (16%) and anastomotic leakage (24%) in the preoperative chemotherapy group was slightly higher than that in the control group (n = 506), and mortality (6.0%) after esophagectomy in the preoperative chemotherapy group was higher than that (2.4%) of the control group. Postoperative morbidity and mortality were observed more frequently in patients who received two cycles of the chemotherapy than those receiving only one cycle. Postoperative complications occurred more frequently in patients suffering high grade toxicities due to the preoperative chemotherapy. The highest preoperative serum creatinine value correlated to that of postoperative period (r = 0.6494). The use of the preoperative chemoradiotherapy with a total exposure dosage of 60 Gy or more significantly increased the postoperative pneumonia rate (67%; p < 0.05) compared to the group receiving 40 Gy or less. The mortality rate (33%) also increased. The second cycle of the preoperative chemotherapy should be cancelled if patients suffer high grade toxicities during or after the first cycle, and the total exposure dosage of the preoperative chemoradiotherapy should be limited to 40 Gy or less.     

Endoscopic treatment of lung cancer invading the airway before induction chemotherapy and surgical resection.

OBJECTIVE: Many patients with advanced lung cancer invading the airway require only palliation; however, induction chemotherapy and surgery may sometimes be considered. Preliminary endoscopic palliation may improve quality of life and functional status, allows better evaluation of tumor extension and contributes to prevent infectious complications. We reviewed our experience with preliminary laser treatment, induction chemotherapy and surgical resection in patients with lung cancer invading the airway. METHODS: Twenty-one patients with stage IIIA and IIIB lung cancer presenting with an 80% unilateral airway obstruction were treated with laser resection, induction chemotherapy and surgery. Spirometry, arterial blood gas analysis, quality of life (QLQ-C30 score) and performance status were recorded before and after laser treatment and after chemotherapy. Complications during chemotherapy, surgical morbidity and mortality, and survival were also recorded. RESULTS: No complications were observed after endoscopic treatment. FEV(1) significantly improved from 1.4+/-0.4 l/s to 2.2+/-0.7 l/s, as well as FVC (from 2+/-0.5 to 3.1+/-0.8 l), and remained stable after chemotherapy. The QLQ-C30 score significantly improved after laser treatment (from 45+/-4.8 to 31+/-2.5) as well as the Karnofsky status (from 76+/-5 to 90). One patient developed pneumonia during induction chemotherapy. Three patients were not operated on. We performed five pneumonectomies (one right tracheal sleeve pneumonectomy) and 13 lobectomies (five associated to a bronchial sleeve resection). One patient (5.5%) died after the operation. Four patients experienced minor postoperative complications. Three-year survival after the operation was 52%. CONCLUSIONS: Preliminary endoscopic palliation of lung cancer invading the airway is feasible, improves evaluation and staging, helps to reduce the incidence of complications during induction chemotherapy without increasing surgical morbidity and mortality.