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。     

Selective Reoperation for Locally Recurrent or Metastatic Pancreatic Ductal Adenocarcinoma Following Primary Pancreatic Resection

Background

Resection of certain recurrent malignancies can prolong survival, but resection of recurrent pancreatic ductal adenocarcinoma is typically contraindicated because of poor outcomes.

Methods

All patients from 1992 to 2010 with recurrent pancreatic cancer after intended surgical cure were retrospectively evaluated. Clinicopathologic features were compared from patients who did and did not undergo subsequent reoperation with curative intent to identify factors associated with prolonged survival.

Results

Twenty-one of 426 patients (5?%) with recurrent pancreatic cancer underwent potentially curative reoperation for solitary local-regional (n?=?7) or distant (n?=?14) recurrence. The median disease-free interval after initial resection among reoperative patients was longer for those with lung or local-regional recurrence (52.4 and 41.1?months, respectively) than for those with liver recurrence (7.6?months, p?=?0.006). The median interval between reoperation and second recurrence was longer in patients with lung recurrence (median not reached) than with liver or local-regional recurrence (6 and 9?months, respectively, p?=?0.023). Reoperative patients with an initial disease-free interval >20?months had a longer median survival than those who did not (92.3 versus 31.3?months, respectively; p?=?0.033).

Conclusion

Patients with a solitary pulmonary recurrence of pancreatic cancer after a prolonged disease-free interval should be considered for reoperation, as they are more likely to benefit from resection versus other sites of solitary recurrence.     

A Population-Based Study on the Management and Outcome in Patients with Locally Recurrent Rectal Cancer

Background Although outcome in patients with rectal cancer has improved with preoperative radiotherapy and total mesorectal excision, local recurrence still remains a problem. The condition is difficult to cure and little is known on whether the prognosis for patients with locally recurrent tumours has changed over time. Few population-based studies have been performed. Method Two thousand three hundred and eighteen patients in Stockholm, Sweden had a potentially curative resection for rectal cancer between 1995 and 2003. Until 2005, 141 (6%) developed a local recurrence. Management and outcome for these patients were studied and compared to a previously analysed cohort of 156 patients with local recurrence, treated 1980–1991. Results Of the 141 patients, 57 (40%) had surgery with a curative intent, 48 (34%) radio- and/or chemotherapy and 36 (26%) symptomatic palliation only. The total 5-year survival was 9%. Twenty-five patients had a potentially curative resection, with a 5-year survival of 57%. The corresponding figures for the 156 patients in the earlier cohort were 4 and 42%. Conclusion Although outcome for patients with local recurrence of rectal cancer is dismal, the prognosis has improved slightly over time. A radical resection is a prerequisite for cure and the proportion having a potentially curative resection has increased. Multidisciplinary management, including optimised preoperative staging and patient selection for surgery, radical surgical approach and more effective adjuvant treatments are necessary to further improve the prognosis. Source of financial support: The Cancer Society in Stockholm.     

Treatment and Outcome of 82 Patients with Angiosarcoma

Background Angiosarcomas are an uncommon type of malignancy that are generally thought to behave usually in a locally aggressive fashion; they often metastasize to distant sites. Methods Patients with a diagnosis of angiosarcoma treated at our institution between 1980 and 2006 were analyzed for patient demographics, tumor characteristics, multimodality treatment, and outcomes. Results A total of 82 patients were divided into those with primary and advanced disease. Overall, the median age was 65 (range, 22–91) years, and 44% of patients were women. Median size of tumors was 3.8 cm, and 76% of tumors were intermediate or high grade. Tumors were located throughout the body: 32 cutaneous, 22 deep soft tissues or organs, 10 radiation or lymphedema field, 8 bone, and 7 nonirradiated breast. Of 46 patients with primary disease, all patients underwent surgical resection, 67% received radiotherapy, and 27% received chemotherapy. Five-year disease-specific survival was 60%, and negative prognostic factors included intermediate or high grade, and tumors arising in a radiated or lymphedema field. Of 36 patients with advanced disease, 36% underwent a palliative operation, 78% received radiation, and 58% received chemotherapy. Median survival was just 7.3 months, and cutaneous tumors predicted a better prognosis compared with other sites. Conclusions Primary angiosarcomas treated with aggressive surgical resection and the addition of radiation for close margins or worrisome pathologic features can result in long-term survival in most patients. The role of adjuvant chemotherapy is unclear. Patients with advanced disease have a poor prognosis, but there can be dramatic responses to chemotherapy in a minority of patients.     

Management of Locally Recurrent Kidney Cancer

Locally recurrent kidney cancer is an uncommon but complicated problem. Due to the recognition of the importance of renal preservation and an increase in the use of nephron-sparing approaches via surgery or ablation, locally recurrent disease is being encountered with greater frequency. Treatments for locally recurrent kidney cancer include radical nephrectomy, repeat or salvage partial nephrectomy, de novo or repeat ablation, observation, or experimental systemic therapy. Each of these options has its own constellation of risks and benefits. When local recurrence is detected, the majority of renal units may be saved, but this often comes at the expense of higher perioperative complication rates, which rise with the number of previous interventions on the ipsilateral kidney. Extensive preoperative patient counseling is required to properly individualize therapy. Referral to a center of excellence should be considered before attempting repeat or salvage renal surgery.     

直肠癌局部复发的诊断与治疗

近20年来,随着对盆腔解剖认识的深入,全直肠系膜切除(TME)概念的普及,术前新辅助和术后辅助治疗的广泛应用,以及各国针对直肠癌采用有效联合治疗技术的不断提高,直肠癌局部复发(LRRC)已有明显下降,但其局部复发率仍有2.6％～11.5％.LRRC进展迅速,对于未行治疗的患者,中位生存期仅3～8个月;若仅给予放疗和(或)化疗而无手术治疗,中位生存期约12～15个月.要进一步提高LRRC的总体治疗效果,需要早期诊断和综合治疗.     

Abdominal Sacral Resection of Locally Recurrent Rectal Cancer

Local recurrence of rectal cancer develops in the posterior bony pelvis as an isolated event in about half of the patients with recurrence. Although radiation can palliate sacral root pain, the disease is usually progressive and is rarely amenable to conventional resection. We have adapted a surgical technique usually used for primary sacral tumors, which permits a complete en bloc excision of recurrent rectal cancer in most instances. This approach consists of a laparotomy with pelvic dissection and mobilization of structures to be resected. The patient is repositioned prone and the posterior pelvis (sacrum and side walls) is then resected with preservation of appropriate nerve roots of the posterior pelvis and the sciatic nerve. Reconstruction is done with muscle and skin flaps. We have done 21 such procedures, of which, 11 were for pelvic recurrence of rectal adenocarcinoma. Seven patients had resections for cure and four had palliative resections of fungating or infected tumors. All but one patient was postabdominal perineal resection and nine patients had been irradiated (3000-9000 rads). Two patients had received up to 9000 rads in separate courses (external beam in one and interstitial radiation in the other). The posterior extent of resection was S1-2 to 5 in six patients; S3 to 5 in three patients, and S4-5 in two patients. Anterior exenteration was performed in three patients and three patients had additional resection of other organs. In the curative resection group, three patients are living free of disease at six, ten, and 52 months, and one patient was NED at 60 months, but has again had tumor recurrance and is living with disease at 65 months. One patient died of disease at 13 months and one patient died of a pulmonary embolus following resection for ureteral obstruction at five months. One postoperative death occurred from a cerebrovascular accident at 52 days. In the palliative resection group, three patients survived with relief of local tumor symptoms four, eight, and 12 months. One patient who had received a total of 9000 rads developed flap necrosis, small bowel fistula and died 60 days after resection. Although this is a small series, it suggests that abdominal sacral resection of locally advanced pelvic cancer is feasible and may provide good palliation in most and possible cure in some patients who develop recurrence after primary resection of adenocarcinoma of the rectum.     

局部复发性胃癌再手术的难点与要点

目的:探讨胃癌局部复发的再手术治疗的难点与要点。方法:总结23例胃癌手术后局部复发的治疗经验与体会。从复习原发灶的生长方式和胃癌的进展方式分析局部复发病变难以切除的原因。结果:残胃复发8例、手术野复发6例及部位不明者9例中,共切除8例,切除率为34.8%。在可切除者中除1例为残胃黏膜下癌,均对手术野粘连和被浸润的脏器进行了合并切除;余者均因癌肿包绕重要血管、脏器而未能切除。结论:初次手术所致的腹腔粘连使局部复发的进展方式发生变化:①复发灶沿粘连带直接浸润的范围广,涉及重要血管、脏器者多。这是造成再切除困难的主要原因;②淋巴结转移途径增多、范围广;③粘连组织包绕残胃,使不易发生腹膜播种。因此,术前宜尽量明确复发的部位和范围,观察原发灶的生长方式有利于判断腹腔内复发的范围和切除的可能性。对被浸润的脏器及其系膜应作足够的切除。术后随诊以早期发现复发也是提高治疗效果的要点。     

Laparoscopic Salvage Surgery for Locally Recurrent Rectal Cancer

Background

Surgical treatment for locally recurrent rectal cancer is challenging, and the value of laparoscopic surgery in such cases is unknown. The purpose of this study was to compare the feasibility of laparoscopic surgery with that of open surgery for locally recurrent rectal cancer.

Methods

Thirty patients with local rectal cancer recurrence at the anastomotic site or lateral pelvic lymph nodes were evaluated. Perioperative outcomes were compared between the laparoscopic (n?=?13) and open (n?=?17) groups.

Results

The median operation time was significantly longer (381 vs. 241 min) but the median estimated blood loss tended to be smaller (110 vs. 450 mL) in the laparoscopic than in the open group. There was only one converted case (7.7 %). The R0 resection rate (100 vs. 94 %) and postoperative complications (31 vs. 24 %) were not significantly different between the two groups. The median times to flatus (1 vs. 2 days), first stool (2 vs. 5 days), and oral intake (2 vs. 5 days) were significantly shorter in the laparoscopic than in the open group.

Conclusion

Laparoscopic surgery for locally recurrent rectal cancer has short-term benefits over open surgery and has potential as a treatment option for locally recurrent rectal cancer.     

Prognostic Parameters,Complications, and Oncologic and Functional Outcome of Salvage Radical Prostatectomy for Locally Recurrent Prostate Cancer after 21st-Century Radiotherapy

Background

Salvage radical prostatectomy (SRP) for radiorecurrent prostate cancer (PCa) is a second local treatment with curative intent in patients with true organ-confined recurrent PCa.

Objective

We evaluated preoperative prognostic risk factors to predict organ-confined, locally recurrent PCa after primary radiotherapy (RT).

Design, setting, and participants

Fifty-five men with biopsy-proven, locally recurrent PCa underwent SRP and extended pelvic lymph node dissection (ePLND) after external-beam radiotherapy (EBRT) or low- or high-dose brachytherapy.

Measurements

Prostate-specific antigen (PSA), clinical stage, biopsy Gleason score prior to RT and SRP, PSA nadir, time to recurrence, PSA doubling time (PSA DT), PSA prior to surgery, and pathohistology of the SRP specimen were analysed to predict organ-confined recurrent disease. Uni- and multivariate statistical analysis was performed.

Results and limitations

Forty (72.7%) and 15 (27.3%) patients demonstrated organ-confined and locally advanced PCa, respectively. Eleven patients (20%) and seven patients (12.7%) had lymph node metastases and positive surgical margins (PSM), respectively. On multivariate analysis, biopsy Gleason score prior to SRP (p = 0.02), <50% positive biopsy cores (p = 0.001), PSA DT >12 mo (p = 0.001), and low-dose brachytherapy (p = 0.001) were significant predictors of organ-confined PCa with negative surgical margins (NSM). Limitations of the study are its retrospective nature and the relatively low number of patients.

Conclusions

SRP is a surgically challenging but effective secondary local treatment of radiorecurrent PCa with curative intent. The identified predictive parameters will help to select patients most suitable for SRP with long-term cure and good functional outcome.     

Symptom Control in Patients With Locally Recurrent Rectal Cancer

Background: Although resection of locally recurrent rectal cancer has been associated with improved survival, clinical outcomes after such repeat surgery have been incompletely characterized.Methods: From 1997 to 1999, 105 consecutive patients requiring repeat surgery for locally recurrent rectal cancer were identified. Patients were observed for a minimum of 2 years or until death.Results: An operation was performed with palliative intent in 23% of patients. Before repeat surgery, 79% of the palliative-intent patients had symptoms: 21% bleeding, 42% obstruction, and 21% pain. After repeat surgery with palliative intent, improvement was noted in 40% with bleeding, 70% with obstruction, and 20% with pain. Additional or recurrent symptoms were noted in 87% during follow-up. Seventy-seven percent of patients had an operation with nonpalliative intent. Before repeat surgery, 57% of nonpalliative patients had symptoms, with 32% experiencing bleeding, 11% obstruction, and 19% pain. After repeat surgery with nonpalliative intent, initial improvement was noted in 88% with bleeding, 78% with obstruction, and 40% with pain. During follow-up, symptoms arose in 37% of the initially asymptomatic patients, and additional or recurrent symptoms were seen in 63% of those previously symptomatic.Conclusions: Although symptomatic relief is associated with repeat surgery, the recurrence or development of alternate symptoms makes a completely asymptomatic clinical course uncommon.     

Radical Resection After IORT-Containing Multimodality Treatment is the Most Important Determinant for Outcome in Patients Treated for Locally Recurrent Rectal Cancer

Background  The optimal treatment for locally recurrent rectal cancer (LRRC) is still a matter of debate. This study assessed the outcome of LRRC patients treated with multimodality treatment, consisting of neoadjuvant radio (chemo-) therapy, extended resection, and intraoperative radiotherapy. Methods  One hundred and forty-seven consecutive patients with LRRC who underwent treatment between 1994 and 2006 were studied. The prognostic values of patient-, tumor- and treatment-related characteristics were tested with uni- and multivariate analysis. Results  Median overall survival was 28 months (range 0-146 months). Five-year overall, disease-free, and metastasis-free survival and local control (OS, DFS, MFS, and LC respectively) were 31.5%, 34.1%, 49.5% and 54.1% respectively. Radical resection (R0) was obtained in 84 patients (57.2%), microscopically irradical resection (R1) in 34 patients (23.1%), and macroscopically irradical resection (R2) in 29 patients (19.7%). For patients with a radical resection median OS was 59 months and the 5-year OS, DFS, MFS, and LC were 48.4%, 52.3%, 65.5% and 68.9%, respectively. Radical resection was significantly correlated with improved OS, DFS, and LC (P < 0.001). Patients who received re-irradiation or full-course radiotherapy survived significantly longer (P = 0.043) and longer without local recurrence (P = 0.038) or metastasis (P < 0.001) compared to patients who were not re-irradiated. Conclusions  Radical resection is the most significant predictor of improved survival in patients with LRRC. Neoadjuvant radio (chemo-) therapy is the best option in order to realize a radical resection. Re-irradiation is feasible in patients who already received irradiation as part of the primary rectal cancer treatment.     

Sentinel Lymph Node Dissection in Locally Recurrent Breast Cancer

Annals of Surgical Oncology - The aim of this study was to investigate the use of sentinel lymph node dissection (SLND) in the treatment of patients with locally recurrent breast cancer. A total of...     

Clinicopathological Assessment of Locally Recurrent Rectal Cancer and Relation to Local Re-Recurrence

Background

Local re-recurrence after R0 resection of local recurrence of rectal cancer (LRRC) is not rare. The purpose of this study was to examine the pathological features of LRRC and determine the prognostic factors.

Methods

Twenty-one patients underwent R0 resection of LRRC without preoperative therapy from 2000 to 2008. Tumor progression patterns were classified into three types: A, expanding type; B, infiltrating type; and C, intermediate type. Distant isolated cancer cells (DICCs) were defined as cancer cells present in isolation and at a distance (>1 mm) from the tumor edge.

Results

Venous invasion was identified in all but one patient (95%). DICCs were observed in 11 of 21 cases. Type A patients had a significantly lower local re-recurrence rate (0/5) compared with type B and/or C patients (11/16, P = 0.012) and a significantly lower incidence of distant metastasis compared with type B and C patients (0/5 vs. 13/16, respectively; P = 0.0028). Multivariate regression analysis identified venous invasion of the primary lesion (P = 0.027) and tumor progression patterns (P = 0.039) as independent predictors of local re-recurrence.

Conclusions

The main features of LRRC were infiltrating growth, venous invasion, and DICCs. Tumor progression patterns correlated with local re-recurrence and distant metastasis. Preoperative adjuvant therapy to terminate peri-tumor cancer cells may be required for better tumor control.     

浸润其他器官及局部复发结、直肠癌的手术治疗

目的：探讨浸润其他器官及局部复发大肠癌手术治疗的效果及手术治疗的要点。方法：回顾性分析本院１９７５年～１９９８年收治的浸润其他器官及局部复发大肠癌的局部浸润情况及合并切除率,直接法统计生存率。结果：①联合切除情况： １１６６例结肠癌中属Ｄｕｋｅｓ Ｄ期者１２３例,占１０．６％,行联合切除者４１例,占全部病例的３．５％,Ｄｕｋｅｓ Ｄ期病例的３３．３％;２ ３５６例直肠癌中属Ｄｕｋｅｓ Ｄ期者３０５例占１２．９％,行联合切除者１１７例,占全部病例的５．０％,Ｄｕｋｅｓ Ｄ期病例的３８．３％。②４１例结肠癌病人合并切除后的５年生存率为５３．８％。③１１７例直肠癌病人合并全盆腔器官切除者２７例,５年生存率为３３．３％（９／２７）,９０例联合部分器官切除后病人的５年生存率为４６．７％（４２／９０）。结论：对浸润其他器官及局部复发大肠癌病人,不论初发或复发,只要病人全身条件具备,应积极采用手术治疗的方法,对延长病人的生存期有重要意义。     

胃癌复发与转移的有关问题及综合治疗

胃癌的治疗经过一百多年的历史演变，患者的生存期和生存质量得到明显提高和改善。但是仍然有半数以上手术患者出现复发和（或）转移，加之三四十年前行胃大部切除者残胃癌的发生．使对胃癌复发与转移的认识及治疗成为胃癌治疗领域里的新课题。     

Simultaneous Bilateral Spontaneous Pneumothorax Secondary to Metastatic Angiosarcoma of the Scalp: Report of a Case

Angiosarcoma is a highly malignant neoplasm, which most often develops on the scalp or face of elderly people. Common distant metastatic sites include the lung, liver, lymph nodes, and skin. We report a case of angiosarcoma manifesting as simultaneous bilateral spontaneous pneumothorax secondary to pulmonary metastases in an 86-year-old man. The pneumothorax preceded the diagnosis of angiosarcoma. Chest computed tomography showed multiple thin-walled cavitary metastatic pulmonary lesions, which increased in size as new lesions appeared over the clinical course of several months. This case suggests that a finding of simultaneous bilateral spontaneous pneumothorax may indicate a serious parenchymal lung disorder.     

Locally Recurrent Rectal Cancer: Prognostic Factors and Long-Term Outcomes of Multimodal Therapy

Background  

Pelvic recurrent rectal cancer is still a challenging clinical problem, and patients generally have a dismal prognosis and a poor quality of life. Surgical resection represents the only potentially curative treatment; neoadjuvant treatments are presently being taken into consideration to increase the resectability rate and to improve long-term survival.