Nerve-sparing Surgery for Advanced Rectal Cancer Patients: Special Reference to Dukes C Patients

Several nerve-sparing operations for advanced rectal cancer that aim to preserve genitourinary function without compromising tumor clearance have been developed in Japan. The aim of this study was to evaluate the survival and local recurrence of these procedures in Dukes B and C patients. A total of 177 patients with advanced rectal cancer underwent curative nerve-sparing surgery (NSS) over the last 11 years; 52 were Dukes B patients and 54 were Dukes C. Altogether 36 had Dukes C1 and 18 had Dukes C2 tumors, 13 with lateral lymph node metastases, designated lateral LN(+). The 5-year survival rate was 92% for Dukes B, 67% for Dukes C1, and 39% for Dukes C2 patients: 11% for Dukes C2 patients with lateral LN(+). The local recurrence rate was 6% for Dukes B, 11% for Dukes C1, and 33% for Dukes C2 patients: 20% for the lateral LN(−) group and 39% for the lateral LN(+) group. Almost all of the patients undergoing NSS could micturate spontaneously, but preservation of sexual function was not as successful. Although there is no guarantee of preserving satisfactory sexual function, our NSS is an acceptable procedure for Dukes B, C1, and C2 patients without lateral lymph node metastases.     

低位直肠癌保留神经的腹膜外侧方扩大清扫的效果分析

目的 探讨低位直肠癌保留神经的腹膜外侧方扩大清扫对患者术后生存率、排尿功能和性功能的影响。方法 回顾性分析我院1996年1月至2000年6月期间收治的392例进展期低位直肠癌实施保留神经的根治性切除术患者的临床资料，其中行腹腔内清扫173例，腹腔内加腹膜外侧方清扫219例，2组患者在年龄、性别、浸润肠壁深度及肿瘤病理组织学类型方面差异无统计学意义。结果 腹腔内加腹膜外侧方清扫组侧方淋巴结转移率为17．8％（39／219），侧方盆壁非连续性癌灶转移率为5，9％（13／219）。术后发生排尿功能障碍：腹腔内清扫组7例（4．0％），腹腔内加腹膜外侧方清扫组113例（51．6％），2组比较差异有统计学意义（P〈0．01）；性功能障碍：腹腔内清扫组93例男性患者中有12例（12．9％），腹腔内加腹膜外侧方清扫组119例男性患者中有62例（52．1％），2组比较差异有统计学意义（P〈0．01）；局部复发率：腹腔内清扫组为16．2％（28／173），腹腔内加腹膜外侧方清扫组为9．6％（21／219），2组比较差异有统计学意义（P〈0．05）；5年生存率：腹腔内清扫组为49．1％（85／173），腹腔内加腹膜外侧方清扫组为59．4％（130／219），2组比较差异有统计学意义（P〈0．05）。结论 低位直肠癌保留神经的腹膜外侧方扩大清扫，可以减少局部复发，提高患者5年生存率，但也会影响患者术后排尿和男性性机能。     

Sphincter-Preserving Operations Following Preoperative Chemoradiation: An Alternative to Abdominoperineal Resection for Lower Rectal Cancer?

BACKGROUND: Sphincter-preserving operations (SPO) for lower rectal cancer are on the rise. In the study reported here, we compared the oncologic outcomes of patients who underwent sphincter-preserving operations following preoperative chemoradiation for lower rectal cancer with the outcome for patients who underwent abdominoperineal resection (APR). METHODS: This prospective study included 87 patients who underwent proctectomy with curative intent for locally advanced rectal cancer that was located less than 6 cm from the anal verge. Forty-four patients had APR with no preoperative treatment. Forty-three patients underwent concurrent chemoradiation therapy (CCRT) consisting of preoperative 5-fluorouracil-based chemotherapy and pelvic radiation (4500-5040 cGy); this was followed 6 weeks later by surgery (SPO/CCRT). The oncologic outcomes between the two groups were compared, and factors affecting survival were evaluated. RESULTS: The median follow-up period was 56.2 months. The overall postoperative complication rates did not significantly differ between SPO/CCRT and APR (32.6% versus 34.2%; p = 0.879). Also, there were no significant differences in the overall recurrence rate (20.9% versus 20.5%; p = 0.956) and 5-year overall survival rate (70.8% versus 62.9%; p = 0.189) between the two groups. By multivariate analysis, only the pathologic N stage was significantly associated with overall survival (p < 0.001). CONCLUSIONS: Sphincter-preserving operation with CCRT could be another option for the treatment of locally advanced lower rectal cancer in patients who are clinically considered for APR, with no deterioration of oncologic outcomes. For patients undergoing curative resection for lower rectal cancer, the pathologic N stage can provide valuable prognostic information about survival.     

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目的 评价盆腔脏器联合切除术（PE）对局部进展期直肠癌的疗效。方法 对12年中79例局部进展期直肠癌PE术后结果进行回顾性总结。结果 全盆腔脏器切除术（TPE）46例，其中保肛TPE5例，TPE联合骶骨切除1例，TPE联合半骨盆切除1例，后盆腔脏器切除术（PPE）33例。根治性切除65例（82．8％），合并症发生率48．6％，手术死亡2例（2．5％），根治术后再复发36例（58．1％），术后1、3、5年生存率75．8％、39．3％、35．8％。根治性切除与大体根治切除术后3年、5年生存率分别为44．2％、40．8％与11．1％、0。结论 PE是目前治疗局部进展期直肠癌有效的方法，积极的根治性切除病灶，可以有效提高其治愈率，改善生活质量。     

Comparative outcome between chemoradiotherapy and lateral pelvic lymph node dissection following total mesorectal excision in rectal cancer

OBJECTIVE: To evaluate comparative outcome between adjuvant postoperative chemoradiotherapy (postoperative CRT) and lateral pelvic lymph node dissection (LPLD) following total mesorectal excision (TME) in rectal cancer patients. BACKGROUND: Although TME results in lower rate of locoregional recurrence compared with conventional surgery, these 2 treatment modalities following TME have not adequately been appraised until the present trend of preoperative chemoradiotherapy. PATIENTS AND METHODS: Between 1995 and 2000, patients with stage II and III rectal cancer underwent TME plus postoperative CRT (n = 309) or LPLD (n = 176). Patients in the postoperative CRT group received 8 cycles of 5-fluorouracil plus leucovorin and 45 Gy pelvic radiotherapy. Patients in the LPLD group underwent lateral lymph node dissection outside the pelvic plexus. RESULTS: The 5-year overall and disease-free survival rates were 78.3% and 67.3% in the postoperative CRT group, respectively, and 73.9% and 68.6% in the LPLD group, respectively, without significant differences between these groups. Patients in the LPLD group with stage III lower rectal cancer had a locoregional recurrence rate 2.2-fold greater than those in the postoperative CRT group (16.7% vs. 7.5%, P = 0.044). Multivariate analysis showed that APR and advanced T-category (T4) were significantly associated with locoregional recurrence, whereas lymph node metastases, high preoperative serum carcinoembryonic antigen, and APR were significantly associated with shortening of disease-free survival. CONCLUSIONS: Postoperative-CRT and LPLD following TME resulted in comparable survival rates, but the locoregional recurrence rate was higher in the LPLD group. These findings suggest that initial surgery is appropriate for rectal cancer patients who are candidates for low anterior resection without extensive local disease (T1-T3), regardless of lymph node status.     

Curative surgery for local pelvic recurrence of rectal cancer

BACKGROUND/AIMS: Local pelvic recurrence of rectal cancer after radical resection has been associated with morbidity and cancer-related death. This study retrospectively evaluated outcome following curative resection for rectal cancer recurring after surgery on the basis of prognosis, type of procedure and perioperative morbidity. METHODS: A total of 85 consecutive patients with local pelvic recurrence of rectal cancer were evaluated. Of these, 43 underwent microscopic curative surgery for local recurrence. Among the 43 patients, 23 underwent surgery alone and 17 received preoperative radiotherapy (40 Gy) (XRT group) in addition to the surgery. Of the 43 patients, 26 were asymptomatic. RESULTS: Curative resection was higher in the recurrences that were associated with implantation, incomplete surgical margin clearance, and intrapelvic lymph node metastasis than in other types of recurrence. With regard to surgical procedure, abdominoperineal resection (APR), with or without sacral resection, was standard following previous sphincter-preserving surgery, while total pelvic exenteration (TPE), with or without sacral resection, was common following previous APR. Local excision was not considered appropriate surgery. There was a high incidence of perioperative morbidity (64%) in patients receiving TPE. Re-recurrence was observed in 18 patients (50%) after curative surgery. After a follow-up of 2 years or more, the local re-recurrence rate was 28%. The overall 5-year survival rate for patients receiving curative resection was 39%, for patients in the XRT group, 51%, and for patients in the surgery-alone group, 24% (p = 0.07). The survival rate in 26 asymptomatic patients was higher than in 17 patients with symptoms, with 5-year survival rates of 62 and 23% (p < 0.05), respectively. The cumulative local control in the preoperative radiotherapy plus en bloc surgery group (XRT group) was significantly better than in the surgery-alone group (p < 0.01), and survival in the XRT group tended to be better than in surgery alone. CONCLUSIONS: These results suggest that careful patient selection according to the pattern of recurrence, area of invasion and presence of symptoms is important for successful curative surgery. Aggressive surgery with adjuvant therapy may lead to an improved salvage rate.     

Preoperative infusional chemoradiation, selective intraoperative radiation, and resection for locally advanced pelvic recurrence of colorectal adenocarcinoma.

OBJECTIVE: The results of preoperative infusional chemoradiation, resection, and selective intraoperative radiation (IORT) boost in 43 previously nonirradiated patients with locally advanced pelvic recurrence of colorectal adenocarcinoma are described. SUMMARY BACKGROUND DATA: After surgery alone 10% to 30% of patients with carcinoma of the distal colon and rectum will develop isolated pelvic recurrence. In most cases, the disease is locally advanced and not amenable to curative resection. Preoperative infusional chemoradiation has been shown to increase resectability and decrease local recurrence in primary locally advanced colorectal cancer. Based on this experience, we initiated a multimodality treatment protocol to treat patients with pelvic recurrence of colorectal adenocarcinoma. METHODS: Forty-three consecutive patients with histologically proven pelvic recurrence of colorectal adenocarcinoma were enrolled on a multimodality treatment protocol. The treatment plan consisted of 5 weeks of concurrent pelvic external beam radiotherapy (45 Gy) with continuous intravenous infusion of 5-fluorouracil and/or cisplatin. This was followed by surgery that included IORT boost (10-20 Gy) for 21 patients and brachytherapy for 4 patients. RESULTS: Forty patients (93%) underwent operation and 33 (77%) underwent resection with curative intent. There were 29 (88%) margin-negative resections. Fifteen patients (48%) underwent sphincter-preserving operations. There were no treatment-related deaths. Twenty-two patients experience perioperative complications. Median follow-up for the 43 patients was 26 months. The local recurrence rate was 36%. Median survival for the patients who underwent resection was 34 months, and actuarial 5-year disease-free and overall survival were 37% and 58%, respectively. CONCLUSIONS: Tumor cytoreduction by preoperative chemoradiation can increase resectability and enable sphincter-preserving surgery in patients with locally advanced pelvic recurrence of colorectal cancer.     

Compatibility, indications, and limits of nerve sparing technique in lateral pelvic lymphadenectomy for advanced rectal carcinoma

The aim of radical surgical treatment of rectal cancer is to control the spread and prevent recurrence of the disease. In an attempt to improve the results of treatment of locally advanced rectal cancer, we advocate an extended surgical approach consisting of total mesorectal excision, lateral pelvic lymphadenectomy and the nerve sparing technique with resection of autonomic nerves whenever these fibers are affected by locally advanced tumor. Nine cases (9.2%) in a personal series of 98 patients with rectal carcinoma, operated on over the period from January 1992 to December 1997, underwent total mesorectal excision, lateral pelvic lymphadenectomy and the nerve sparing technique procedures for locally advanced extraperitoneal disease. In 7 patients with stage II or III disease, the 5-year survival rate was 80% and the 5-year disease-free survival rate 66.7% after a mean follow-up of 55 months. None of them experienced local recurrence, but one patient died of diffuse metastatic disease 50 months after surgery. One patient with stage IV rectal cancer died of disease 13 months postoperatively, while another patient with the same stage of disease is still alive with disease 26 months after surgery. One patient underwent liver resection for a solitary metastasis 25 months after the primary operation. Two patients suffered postoperatively from urinary retention with mild irregular flow at urodynamic testing, but no long-term urinary disturbances persisted. Retrograde ejaculation occurred postoperatively in one of the two patients who experienced urinary disorders, and another patient had erection disturbances. These sexual dysfunctions did not improve during long-term follow-up. Total mesorectal excision, lateral pelvic lymphadenectomy, and the nerve sparing technique, with resection of the autonomic nerves whenever these fibers are involved, allow satisfactory results to be achieved in terms of survival and functional outcome in patients with locally advanced rectal cancer. In western subjects, however, this procedure is safe only after careful patient selection.     

Resection of Isolated Pelvic Recurrences After Colorectal Surgery: Long-Term Results and Predictors of Improved Clinical Outcome

Background Recurrence in the pelvis after resection of a rectal or rectosigmoid cancer presents a dilemma. Resection offers the only reasonable probability for cure, but at the cost of marked perioperative morbidity and potential mortality. Clinical decision making remains difficult. Methods Patients who underwent resection with curative intent for isolated pelvic recurrences after curative colorectal surgery from 1988 through 2003 were reviewed retrospectively. Clinical and pathological factors, salvage operations, and complications were recorded. The primary measured outcome was overall survival. Univariate and multivariate analyses were conducted to identify prognostic factors of improved outcome. Results Ninety patients underwent an attempt at curative resection of a pelvic recurrence; median follow-up was 31 months. Complications occurred in 53% of patients. Operative mortality occurred in 4 (4.4%) of 90 patients. Median overall survival was 38 months, and estimated 5-year survival was 40%. A total of 51 of 86 patients had known recurrences (15 local, 16 distant, 20 both). Multivariate analysis revealed that preoperative carcinoembryonic antigen level and final margin status were statistically significant predictors of outcome. Conclusions The resection of pelvic recurrences after colorectal surgery for cancer can be performed with low mortality and good long-term outcome; however, morbidity from such procedures is high. Low preoperative carcinoembryonic antigen and negative margin of resection predict improved survival.     

The indications for autonomic nerve-sparing surgery in rectal cancer patients

Although extended lymph node dissection was developed to improve the therapeutic result in advanced rectal cancer in the 1970s, postoperative dysfunction remained problematic. Informed consent of cancer is generalized at present. The balance between complete cure and functional preservation is important. Therefore the autonomic nerve-sparing surgical technique for rectal cancer was introduce din the 1980s. The success of nerve-sparing surgery depends on a thorough knowledge of pelvic anatomy, especially the anatomic relationship between the pelvic plexus and internal intestinal vessels. Further investigation is required to clarify the indications for autonomic nerve-sparing surgery in rectal cancer patients.     

Therapy results of locoregional recurrences in rectal cancer

Despite of advanced surgical technique and multimodality therapy results following secondary resection of local recurrence after rectal cancer are discussed controversially. PATIENTS AND METHODS: Between 1990 and 1999 81 patients with local recurrence of rectal cancer were treated at our surgical department. Median age was 63 years, 62 % of patients were male. 98 % of recurrences were in local advanced stage (74 % = rT4, 25 % = rT3), 44 % of patients had synchronous distant metastases. RESULTS: 32 patients underwent resection of recurrent rectal cancer. Potential curative surgery was possible in 56 % of resections. Extended resections of adjacent organs were necessary in 21 patients. The 4-year survival in the curative group was 44 % compared to 19 % in patients with microscopic or gross residual disease. CONCLUSION: Optimistic long-term results in recurrent rectal cancer can only be achieved after curative resection. Preoperative radiochemotherapy in advanced cancers increases curative resection and probably survival rate.     

The long-term voiding function and sexual function after pelvic nerve-sparing radical surgery for rectal cancer

BACKGROUND: The aim of the present study is to symptomatically analyze the extent to which pelvic nerve-sparing radical surgery for rectal cancer impacts on long-term voiding and male sexual function. METHODS: A self-administered questionnaire was mailed to 68 patients who underwent pelvic nerve-sparing radical surgery for invasive rectal cancer with 52 responses (28 men and 24 women; 27 complete and 25 incomplete preservation; response rate 76.5%). Each patient was asked to record if there had been any changes in lower urinary tract symptoms after surgery. Sexual function was also investigated in men. RESULTS: Of the 52 patients, 48 (92%) maintained voluntary voiding without catheterization in the long term. Clean intermittent self-catheterization was performed in only four patients with incomplete preservation because of persistent voiding dysfunction. Subjectively, approximately 60% of the patients remained unchanged in lower urinary tract symptoms after surgery. The satisfaction rate regarding the current voiding status was significantly higher in women than in men (83% versus 61%, P = 0.0294), but was not significantly different between those with complete (76%) and incomplete preservation (64%). Despite the acceptable urinary status, 88% of men had some deterioration in the erectile function, regardless of the types of surgical procedures. Overall, 64% of men were unsatisfied with the current sexual function. CONCLUSIONS: Pelvic nerve-sparing radical surgery for rectal cancer preserved the long-term voiding function in the majority of patients. In completely preserved patients and in women, symptomatic outcomes were more satisfactory. Postoperative erectile dysfunction was found to be a serious problem, even in complete nerve-sparing procedure.     

Standardized treatment of colorectal cancer. A prospective study

304 patients with colorectal adenocarcinoma underwent standardized, aggressive treatment which included wide resection, adjuvant radio- or chemotherapy and management of advanced disease. The mean age of the patients was 68 years; 50% were older than 70 years, and 17% above 80 years. The resectability rate was 86.2%. Overall postoperative mortality was 7.3%, in patients operated on for cure 5.7%, and in patients more than 80 years 16.3%. The highest postoperative mortality was seen following right hemicolectomy and deaths were mainly caused by anastomotic leakage and myocardial infarction. In patients with primarily inoperable rectal cancer treated with irradiation and followed by attempted curative surgery, the estimated 5-year survival was 38%. In patients with operable rectal cancer treated with preoperative irradiation followed by surgery the 5 year survival was 69% as compared to 45% for those treated with surgery only. Adjuvant cytostatic therapy in patients with colonic tumours of Dukes B and C stages did not improve survival.     

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??Radiotherapy of locally recurrent rectal cancer GAO Xian-shu, LI Hong-zhen. Department of Radiation Oncology, Peking University First Hospital, Beijing 100034, China
Corresponding author: LI Hong-zhen, E-mail??doclee0134@163.com
Abstract Local recurrence is the most common clinical failure pattern of rectal cancer, especially in stage II/III rectal cancer cases. The prognosis of postoperative recurrence is poor. To prevent recurrence, related studies on adjuvant/neoadjuvant chemoradiotherapy of locally advanced rectal cancer after surgery started in the 1970s. A large number of clinical trial results showed that preoperative and postoperative adjuvant/neoadjuvant chemoradiotherapy of locally advanced rectal cancer may reduce local recurrence, improve sphincter rate and survival. The pattern of multiple discipline treatment has become an evidence-based medicine I class as a standard treatment options of locally advanced rectal cancer. Chemoradiotherapy of locally recurrent rectal cancer has not yet achieved a high level of evidence-based medicine. NCCN guidelines recommend against recurrent rectal cancer patients should be performed multidisciplinary and comprehensive treatment. For isolated recurrent pelvic or anastomosis, if patients have not received the full amount of radiation, the most appropriate treatment is preoperative radiotherapy, concurrent chemotherapy. In conditional medical institutions, preoperative neoadjuvant chemoradiotherapy plus surgery and intraoperative radiotherapy may be considered.     

Patterns of pelvic invasion are prognostic in the treatment of locally recurrent rectal cancer.

BACKGROUND: Local recurrence of rectal cancer after curative resection remains a difficult clinical problem. The aim of this study was to elucidate prognostic risk factors after resection of recurrent cancer. METHODS: Between January 1983 and December 1999, 83 patients with locally recurrent rectal cancer were studied retrospectively for survival benefit by re-resection. Sixty patients underwent resection for recurrent cancer, including total pelvic exenteration in 30 patients and sacrectomy in 23 patients. The extent of locally recurrent tumour was classified by the pattern of pelvic invasion as follows: localized, sacral invasion and lateral invasion. RESULTS: Multivariate analysis showed that the pattern of pelvic invasion was a significant prognostic factor which independently influenced survival after resection of recurrent cancer (P < 0.001). The 5-year survival rates were 38 per cent in the localized type (n = 27), 10 per cent in the sacral invasive type (n = 16) and zero in the lateral invasive type (n = 17). CONCLUSION: Resection for locally recurrent rectal cancer is potentially curative in patients with localized or sacral invasive patterns of recurrence. Alternatives should be explored in patients with recurrence involving the lateral pelvic wall.     

Radical resection with autonomic nerve preservation and lymph node dissection techniques in lower rectal cancer surgery and its results: the impact of lateral lymph node dissection

Lateral lymph node metastases occur in 9% of rectal cancer patients. For cancers localized in the lower rectum below peritoneal reflection, the frequency increases to 13% of all cases and to 25.5% in those of Dukes' stage C. The most important technique in colorectal surgery for decreasing local failure in the pelvis is lateral lymph node dissection. Today, however, it is also regarded as crucial that with perfect lymph node dissection of the lateral area outside of the pelvic plexus, the postoperative functions of urination and sexual ability are preserved. Since 1988 we have performed autonomic nerve-preserving curative resection (ANP) with lateral dissection in most patients with advanced lower rectal cancer. The mean 5-year survival rate of patients with lateral lymph node metastasis from the lower rectum was 37.5%, improving from 32.1% to 43.4% during this period. In cases of ANP with lateral dissection the local recurrence rate was 4.8% overall and 7.4% in the Dukes' C group. Postoperative urinary function has been good or fair in all ANP patients. Sexual function remained problematic, especially regarding male ejaculation. We describe our method for preserving the autonomic nervous system in the pelvis and for achieving complete dissection in the lateral area. Received: 20 August 1998 / Accepted: 14 October 1998     

Resection of Isolated Pelvic Recurrences after Colorectal Surgery: Long-Term Results and Predictors of Improved Clinical Outcome

Background Recurrence in the pelvis after resection of a rectal or rectosigmoid cancer presents a dilemma. Resection offers the only reasonable probability for cure, but at the cost of perioperative morbidity and potential mortality. Clinical decision making remains difficult. Methods Patients resected with curative intent for isolated pelvic recurrences after curative colorectal surgery from 1988 through 2003 were reviewed retrospectively. Clinical and pathologic factors, salvage operations, and complications were recorded. The primary measured outcome was overall survival. Univariate and multivariate analyses were conducted to identify prognostic factors of improved outcome. Results Ninety patients underwent an attempt at curative resection of a pelvic recurrence with median follow-up of 31 months. Complications occurred in 53% of patients. Operative mortality was 4.4% (4 of 90). Median overall survival was 38 months, and estimated 5-year survival was 40%. A total of 51 of 86 patients had known recurrences (15 local, 16 distant, 20 both). Multivariate analysis revealed that preoperative carcinoembryonic antigen level and final margin status were statistically significant predictors of outcome. Conclusions The resection of pelvic recurrences after colorectal surgery for cancer can be performed with low mortality and good long-term outcome; however, morbidity from such procedures is high. Low preoperative carcinoembryonic antigen and negative margin of resection predict improved survival. Presented at the Society of Surgical Oncology, 58th Annual Cancer Symposium, Atlanta, GA, March 3–6, 2005.     

Oncologic Outcomes After Radical Surgery Following Preoperative Chemoradiotherapy for Locally Advanced Lower Rectal Cancer: Abdominoperineal Resection Versus Sphincter-Preserving Procedure

Background  Over the past several years, preoperative chemoradiotherapy (CRT) has contributed remarkably to make more sphincter-preserving procedure (SPP) possible for lower rectal cancer. The aim of this study was to compare the outcomes between abdominoperineal resection (APR) and SPP after preoperative CRT in patients with locally advanced lower rectal cancer. Methods  A retrospective investigation was conducted with a total of 122 patients who underwent radical surgery combined with preoperative CRT for locally advanced lower rectal cancer. Of these, 50 patients underwent APR and 72 received SPP. Surgery was performed 6–8 weeks after completion of preoperative CRT. Oncologic outcomes were compared between the two groups, and the clinicopathologic factors affecting the treatment outcomes were evaluated. Results  Circumferential resection margin (CRM) involvement (P = 0.037) and postoperative complication rate (P = 0.032) were significantly different between APR and SPP. Patients who underwent APR had a higher 5-year local recurrence (22.0% vs. 11.5%, P = 0.028) and lower 5-year cancer-specific survival (52.9% vs. 71.1%, P = 0.03) rate than those who underwent SPP. Pathologic N stage was the most critical predictor for local recurrence and survival. Conclusions  Our study shows that APR following preoperative CRT exhibited more adverse oncologic outcomes compared with SPP. This result may be due to higher rates of CRM involvement in APR even with preoperative CRT. We suggest that sharp perineal dissection and wider cylindrical excision at the level of the anorectal junction are required to avoid CRM involvement and improve oncologic outcomes in patients who undergo APR following preoperative CRT.     

Surgical Resection of Hilar Cholangiocarcinoma: Analysis of Survival and Postoperative Complications

Background Surgery is the only potentially curative treatment for hilar bile duct cancer. This study sought to evaluate the efficacy and feasibility of surgical management of hilar bile duct carcinoma, including radical hepatectomy, at a single institution. Methods We performed a retrospective review of 49 consecutive patients who underwent surgery at our hospital between 1990 and 2003. Results Altogether, 44 of 49 patients underwent radical hepatectomy combined with caudate lobectomy and lymphadenectomy. One and four patients underwent partial hepatectomy or bile duct resection, respectively. No patients underwent preoperative portal vein embolization. The 5-year survival rate was 39.7%, with a median survival time of 3.75 years. The postoperative morbidity and mortality rates were 46.8% and 2.0%, respectively. Cox’s proportional hazard model revealed that lymph node status and the residual tumor factor were independent prognostic factors. Multivariate analysis revealed that preoperative hyperbilirubinemia, postoperative complications, and extended surgical procedures were independently associated with postoperative hyperbilirubinemia. After potentially curative resection, 39.4% of patients suffered from disease recurrence. In 60% of the total cases, the sites of recurrence were distant metastases. Conclusion Surgery, including radical hepatectomy combined with caudate lobectomy and lymph node dissection, is a feasible, effective treatment for hilar bile duct cancer.     

Curative potential of multimodality therapy for locally recurrent rectal cancer

OBJECTIVE: To assess the results of multimodality therapy for patients with recurrent rectal cancer and to analyze factors predictive of curative resection and prognostic for overall survival. SUMMARY BACKGROUND DATA: Locally recurrent rectal cancer is a difficult clinical problem, and radical treatment options with curative intent are not generally accepted. METHODS: A total of 394 patients underwent surgical exploration for recurrent rectal cancer. Ninety were found to have unresectable local or extrapelvic disease and 304 underwent resection of the recurrence. The latter patients were prospectively followed to determine long-term survival and factors influencing survival. RESULTS: Overall 5-year survival was 25%. Curative, negative resection margins were obtained in 45% of patients; in these patients a 5-year survival of 37% was achieved, compared to 16% (P <.001) in patients with either microscopic or gross residual disease. In a logistic regression analysis, initial surgery with end-colostomy and symptomatic pain (both univariate) and increasing number of sites of the recurrent tumor fixation in the pelvis (multivariate) were associated with palliative surgery. Overall survival was significantly decreased for symptomatic pain (P <.001) and more than one fixation (P =.029). Survival following extended resection of adjacent organs was not different from limited resection (28% vs. 21%, P =.11). Patient demographics and factors related to the initial rectal cancer did not affect outcome. Perioperative mortality was only 0.3%, but significant morbidity occurred in 26% of patients, with pelvic abscess being the most common complication. CONCLUSIONS: This study demonstrates that many patients with locally recurrent rectal cancer can be resected with negative margins. Long-term survival can be achieved, especially for patients with no symptoms and minimal fixation of the recurrence in the pelvis, provided no gross residual disease remains.