Clinical advantages of laparoscopic colorectal cancer surgery in the elderly

BACKGROUND AND AIMS: Elderly patients have a high incidence of colorectal cancer, which may be associated with increased morbidity and mortality due to complex comorbidity and diminished cardiopulmonary reserves. The aims of this study were to compare the outcomes of laparoscopic colorectal cancer surgery with those observed in traditional open surgery in patients aged over 70 years. METHODS: Between January 2003 and October 2004, 51 patients aged over 70 years with colorectal cancer, who underwent laparoscopic surgery (LAP group), were evaluated and compared with 102 controls (also over 70 years old) treated by traditional open surgery (OPEN group) in the same period. All patients were evaluated with respect to the American Society of Anesthesiologists (ASA) classification, surgery-related complications, and postoperative recovery. RESULTS: No surgery-related death was observed in the LAP group, whereas two deaths occurred in the OPEN group for severe post-operative pulmonary infection and anastomotic leak, respectively. No pneumoperitoneum-related complications were observed in the LAP group; 2 (3.9%) patients required conversion to open surgery, because of the unexpectedly bulky tumor and severe adhesions in the abdominal cavity. With the increase in patients' age, increased ASA classification was observed. No significant differences were observed in gender, Dukes' staging or types of procedures between LAP and OPEN groups. The overall morbidity in the LAP group was significantly less than that of the OPEN group [17.6% (9/51) vs 37.3% (38/102), p=0.013]. Mean blood loss, time to flatus passage, and time to semi-liquid diet in the LAP group were significantly shorter than those of the OPEN group (90.7+/-49.9 vs 150.3+/-108.7 ml, 2.4+/-1.2 vs 3.5+/-2.9 d, 5.0+/-1.8 vs 5.9+/-1.2 d, respectively, p<0.05). No significant differences were observed in terms of mean operation time or hospital stay between LAP and OPEN groups. CONCLUSION: Laparoscopic colorectal cancer surgery in elderly patients with colon cancer has clinically significant advantages over traditional open surgery, and appears to be the ideal surgical choice for the elderly.     

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

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

Surgical results in 657 patients with colorectal cancer

Six hundred fifty-seven patients with colorectal cancer who were operated upon at the Second Department of Surgery, Helsinki University Central Hospital during the period 1966 to 1975 had a 40.5 per cent crude five-year survival rate and 54.2 per cent relative (corrected) rate. The survival rates of patients with Dukes' A lesions were 80.7 per cent, Dukes' B, 61.6 per cent, Dukes' C, 40.4 per cent, and Dukes' D, 2.7 per cent. One hundred two patients (15.5 per cent) underwent emergency operations; 91 were occlusive cancers, eight were perforations and three were cancer bleedings. The operative mortality for the whole series was 6.5 per cent (4.7 per cent in elective and 16.7 per cent in emergency operations). A definite improvement of the five-year survival rates could be seen in both the colonic and rectal cancer series. This was due to earlier detection of the disease, reflecting a decreasing number of palliative operations. Patients at high risk for colorectal cancer (inflammatory bowel disease, inherited intestinal polyposis, cancer family syndrome, multiple colorectal cancers, and neoplastic polyps) might benefit from more effective cancer surveillance and prophylactic surgery to find and treat cancers in earlier stages, to prevent recurrences, and to facilitate follow-up. The controversial findings on postoperative adjuvant therapy presented in this study indicate the need for further controlled studies to define the patients who really benefit from it.     

Conservative surgery for early cancer of the distal rectum

From 1967 through 1988, 36 patients underwent local excision of a distal rectal cancer as an initial operative procedure with curative intent. A diagnostic, preoperative protocol was performed to assess the histologic grade of the tumor, the depth of penetration in the rectal wall, and the presence of positive lymph nodes or distant metastases. All patients had a transanal local excision performed under general anesthesia. If preoperative criteria were not confirmed by histopathologic specimen examination, a major operation was advised. To increase the chance of local control, external adjuvant radiotherapy was used in T2 cancers. Postoperative mortality was 0 percent. The postoperative complication rate was 9.3 percent. The observed local recurrence rate was 3 percent, and the rectal cancer-specific death rate was 6 percent. We compared these results with those obtained in 70 concomitant patients operated on by us employing a traditional resection for Dukes' A rectal cancer. There are no statistically significant differences between groups. In light of our findings, a policy of curative local excision is justified in accurately selected cases of distal rectal cancer.     

Characteristics and survival rate of elderly patients with colorectal cancer detected by immunochemical occult blood screening

BACKGROUND/AIMS: A comparative study was carried out to clarify the clinicopathological features and survival rate of elderly patients with colorectal cancer diagnosed by immunochemical fecal occult blood screening. METHODOLOGY: The study subjects included 208 patients with colorectal cancer, who were divided into 2 groups based on their ages: 52 patients aged 75 years and over (older group) and 156 patients aged 50-74 years (younger group). The 2 groups were compared in terms of their individual factors, including site, size, Dukes' classification, histo-pathological type of their cancer lesions and 5-year survival rate. RESULTS: There was a significant difference in prevalence of tumor sites between the older and younger groups (P < 0.05). Particularly, the frequency of right colon cancers was higher in the older group (34.6%) than in the younger group (20.5%), but there were no differences found in any other factors such as size, Dukes' classification, and histopathological type. Survival rate was almost the same between the 2 groups. CONCLUSIONS: These results suggest that elderly patients are susceptible to right colon cancer but there is no difference in the clinicopathological characteristics and 5-year survival rate between older and younger patients with colorectal cancer detected by immunochemical fecal occult blood test. The older as well as younger people should be encouraged to attend the screening program for colorectal cancer by immunochemical fecal occult blood test.     

Influence of prophylactic apical node dissection of the inferior mesenteric artery on prognosis of colorectal cancer

BACKGROUND/AIMS: Middle ligation (ML) of the inferior mesenteric artery (IMA) maintains adequate blood supply to an anastomosis and has no risk of autonomic nerve injury. If apical node dissection of the IMA improves the prognosis, ML and prophylactic dissection of the apical node without division of the IMA above the colic artery may also result in an additional prognostic improvement in patients with sigmoid colon or rectal cancer. METHODOLOGY: Four hundred and one patients with either Dukes' B or Dukes' C colorectal cancer were clinicopathologically examined. In order to evaluate the influence of the prophylactic dissection of the apical node on the prognosis, the two groups of ML with and without apical node dissection were compared. RESULTS: The 5-year survival rates in the groups of ML and ML with apical node dissection were 90% and 91%, respectively, in 218 Dukes' B patients. The 5-year survival rates in the groups of ML and ML with apical node dissection were 73% and 71%, respectively, in 183 Dukes' C patients. There were no significant differences between the two groups in both Dukes' B and Dukes' C patients. CONCLUSIONS: When ML is adopted for patients with sigmoid colon or rectal cancer, additional dissection of the apical node is not needed.     

70岁以上食管癌和贲门癌患者的开胸手术分析

目的 探讨高龄食管癌和贲门癌患者的外科手术选择及围手术期处理方法 . 方法 回顾性分析1088例食管癌和贲门癌患者的临床资料,分为70岁以下(41～69岁)、70～74岁、75～79岁、80岁以上(80～90岁)4组.统计4组患者术后并发症、住院时间及预后,并对手术选择和围手术期治疗措施进行分析. 结果 70岁以上食管癌和贲门癌患者术后肺部感染、心律失常、精神症状和切口不愈的发生率明显上升,术后住院时间明显延长;80岁以上的高龄患者术后肺部感染发生率和术后住院时间较其他年龄段明显上升.全组痊愈1084例,死亡4例. 结论 在高龄食管癌和贲门癌患者中,了解开胸术后并发症发生状况,加强对肺部感染的预防和治疗是决定手术成败的关键.     

Colon resection in elderly patients: comparison of data of a single surgical department with collective data from the Czech Republic

Colorectal cancer is predominantly a disease of elderly people, since over 70% of cases occur in those aged 65 years or older. Clinicians have to frequently decide whether major surgery is justified in elderly patients with a limited life expectancy. Our retrospective study was aimed to compare outcomes of primary surgery for colorectal cancer in the elderly patient population. The evaluated data were collected from the 1st Department of Surgery, Charles University, and from all over the Czech Republic. Patients were divided into three groups: the young-old (21-59 years), the older-old (60-69 years), and the oldest-old (>69 years) patients. In the collective data the youngest and the oldest groups differ significantly in the rate of early postoperative complications (12.3% versus 17.6%, p<0.001). The number of complications associated with the emergency procedures was twice as high compared to elective surgery in all groups (p<0.001). There was no correlation between age and length of hospital stay in the single surgery department. These data suggest that major oncology procedures may be undertaken in older patients in whom operative risk is reasonable, with acceptable rates of complications.     

Laparoscopic mesorectal excision with preservation of the pelvic autonomic nerves for rectal cancer

BACKGROUND/AIMS: Laparoscopic mesorectal excision with preservation of the autonomic pelvic nerves for rectal cancer including selected advanced lower rectal cancer is now challenging. The aims of the study were to assess the surgical results and short-term outcomes of this procedure prospectively. METHODOLOGY: Seventy-four of 281 rectal cancer patients, since the introduction of laparoscopic colorectal surgery in our hospital, have undergone laparoscopic rectal surgery. The location of the tumor distributed in upper rectum; 33, middle; 22, and lower 19. The mesorectal excision with preservation of the autonomic pelvic nerves was performed for all the patients. The laparoscopic mesorectal excision was performed under 8 to 10 cmH2O CO2 pneumoperitoneum and lymph node dissection was performed along the feeding artery depend on individuals. Ipsilateral lateral lymph node dissection was added for 5 cases of advanced lower rectal cancer. RESULTS: Open conversion occurred in 4 cases, 2 of those were due to locally advanced tumors and 2 technical difficulties in transaction of the distal rectum. There were 15 postoperative complications, 7 anastomotic leakage (10.6%), 3 transient urinary retention (4.1%), 4 wound infection (5.3%), and 1 small bowel obstruction (1.4%). No mortality was recorded in this series. Time of operation was 203 +/- 54 min in mesorectal excision cases and 270 +/- 42 min mesorectal excision with lateral lymph node dissection cases. Blood loss was 92 +/- 90g and 276 +/- 66 g respectively. The hospital length-of-stay was 11.7 days in average. CONCLUSIONS: Laparoscopic mesorectal excision with preservation of autonomic pelvic nerves for rectal cancer patients including selected advanced lower rectal cancer is favorable.     

Emergency surgery for patients with colorectal cancer over 90 years of age

BACKGROUND/AIMS: Colorectal cancer has an extremely poor prognosis in the elderly with high rates of emergency presentation and perioperative mortality. This report examines our experience and results in the emergency treatment of patients older than 90 years with colorectal cancer. METHODOLOGY: From 1995 to 2000, 486 patients with colorectal cancer were operated on in an emergency surgery situation at the Department of Emergency Surgery of Sant'Orsola-Malpighi University Hospital. A retrospective analysis of 20 patients aged 90 or older was carried out. RESULTS: Thirteen patients underwent resection of the primary growth and anastomosis and 7 subjects with carcinomatosis had palliative intervention by creating a stoma only or bypass anastomosis without resection. We registered two deaths caused by respiratory insufficiency and 2 postoperative complications successfully treated with medical therapy. CONCLUSIONS: Emergency surgery for colorectal cancer in patients over 90 years of age can be performed safely without restrictions related to the age.     

Progress in sigmoidectomy for cancer during the last 24 years in our department

BACKGROUND/AIMS: In the treatment for colon cancer, changes may have taken place in areas such as surgical devices, concepts for basic strategies, composition of the medical team, postoperative management and adjuvant chemotherapy. No one knows the net effect of these alterations in treatment on sigmoid colon cancer patients. METHODOLOGY: A total of 147 patients were divided into 2 groups based upon the time of the surgery. Comparisons were made based upon the several parameters, including survival. In addition, to determine the effect of the degree of lymph node dissection on survival, patients were divided into 3 groups based upon the ligated portion of artery. RESULTS: Blood loss significantly decreased. Other factors were almost the same except for survival. In Dukes' A and B, 5-year survival rates were the same (90%). But in Dukes' C, the 5-year survival rate was better in the later period (90%) than in the earlier period (70%). In Dukes' C, the extent of lymph node dissection significantly influenced the survival. CONCLUSIONS: The parameters have not changed very much in these 24 years except for the 5-year survival rates in Dukes' C. The extent of lymph node dissection is probably sufficient just below the root of left colic artery.     

Overexpression of cyclooxygenase-2 correlates with advanced stages of colorectal cancer

OBJECTIVE: We aimed to investigate the associations of cyclooxygenase-2 (COX-2) with pathological features and survival in patients with colorectal cancer. METHODS: The expression of COX-2 was examined by immunohistochemistry in 112 primary colorectal cancers, with 64 samples from the corresponding normal mucosa and 16 metastases in the regional lymph nodes of patients with colorectal cancer. The associations of COX-2 expression with clinicopathological features, including survival, were analyzed. RESULTS: The frequency and intensity of COX-2 staining were remarkably increased from the normal samples (17%) to the primary tumors (72%) and to the metastases (100%). Expressions of COX-2 were 25%, 74%, 78%, and 67% in Dukes' A, B, C, and D tumors, respectively (p = 0.005), and positively related to proliferative activity (p = 0.003). COX-2 expressions were 80% in colonic tumors and 60% in rectal tumors (p = 0.03). The expression of COX-2 was positively related to the better differentiated tumors in the colon (p = 0.04). We were unable to find any relationship of COX-2 with patient age, sex, tumor growth pattern, apoptosis, and patient survival (p > 0.05). CONCLUSION: We found that the expression of COX-2 was upregulated from normal cells to primary tumors and to metastases, and related to proliferative activity, tumor location, Dukes' stage, and differentiation. These results further support the evidence that COX-2 may be involved in tumorigenesis and development of colorectal cancer.     

Comparing risks and benefits of colorectal cancer screening in elderly patients

BACKGROUND & AIMS: In patients with limited life expectancy, the risks of colorectal cancer screening may outweigh the benefits. The aim of this study was to quantify risks and benefits of different screening strategies in elderly patients with varying life expectancies. METHODS: We examined risks and benefits of screening in patients aged 70-94 years with differing health status using 3 strategies: annual fecal occult blood tests, flexible sigmoidoscopy every 5 years, or colonoscopy every 10 years. We compared the number needed to screen to prevent one cancer-related death and the number needed to encounter one screening-related complication for different strategies. RESULTS: The potential benefit from screening varied widely with age, life expectancy, and screening modality. One cancer-related death would be prevented by screening 42 healthy men aged 70-74 years with colonoscopy, 178 healthy women aged 70-74 years with fecal occult blood tests, 431 women aged 75-79 years in poor health with colonoscopy, or 945 men aged 80-84 years in average health with fecal occult blood tests. Colonoscopy screening had the greatest benefit but the highest risk of complications. The potential for screening-related complications was greater than estimated benefit in some population subgroups aged 70 years and older. At all ages and life expectancies, the potential reduction in mortality from screening outweighed the risk of colonoscopy-related death. CONCLUSIONS: The potential benefits and risks of screening vary in elderly patients of different life expectancies. For any individual patient, the potential for harm from screening must be weighed against the likelihood of benefit, especially with shorter life expectancy.     

Morbidity and Mortality of Laparoscopy-Assisted Gastrectomy with Extraperigastric Lymph Node Dissection for Gastric Cancer

Gastrectomy with extraperigastric lymph node dissection has not been generally acceptable because of increased morbidity and mortality in some Western countries. Recently, many surgeons have become interested in laparoscopic gastric surgery for malignant disease as well as benign lesions because laparoscopic surgery itself has been shown to have many advantages over open surgery. The aims of this study are to evaluate the incidence and nature of operative morbidity and mortality after laparoscopy-assisted gastrectomy (LAG) with extraperigastric lymph node dissection with respect to surgical experience and to identify factors predictive of complications and death. We reviewed the surgical outcomes of LAG with extraperigastric lymph node dissection in 140 consecutive gastric cancer patients. Clinicopathologic characteristics, operative outcomes, and postoperative morbidities and mortalities were compared after dividing the 140 patients into early (1–70) and late (71–140) groups. And risk factors for morbidity and mortality were identified by multivariate logistic regression analysis. The overall operative morbidity and mortality rates were 18.6% and 0.7%, respectively. Thirty postoperative complications occurred in 26 patients. The minor surgical complication rate in the late group was significantly lower than that in the early group (P = 0.0349). According to univariate and multivariate analyses to evaluate the independent predictor of a higher operative morbidity rate, no factor was significantly associated with operative morbidity. We conclude that LAG with extraperigastric lymph node dissection is a technically feasible and acceptable surgical modality for gastric cancer and low morbidity and mortality rates for this procedure can be accomplished by experienced laparoscopic gastric surgeons at large-volume hospitals.     

Poor prognosis of colorectal cancer in patients over 80 years old is associated with down-regulation of tumor suppressor genes

GOALS, BACKGROUND: The elderly population has been increasing during the last half a century and it would be important to know how aging influences the occurrence and biologic behavior of cancers. STUDY: We investigated clinicopathologic characteristics of colorectal cancer in 1354 patients who underwent colorectal cancer resection and compared the results between extremely elderly patients (over 80 years old) and middle-aged/elderly patients (40 to less than 80 years old). Furthermore, we also examined expression of tumor suppressor genes and Cox-2 using frozen samples of colorectal cancer obtained from 62 patients ranging in age from 45 to 87 years. RESULTS: The results obtained in the extremely aged patients were: (1) higher ratio of women, (2) higher incidence at the proximal site, (3) higher incidence of cases with deeper invasion, (4) higher incidence of cases with lymph node metastasis (5) poorer survival rate as compared with middle-aged/elderly patients, and (6) lower mRNA expression levels of p27 and p53. CONCLUSIONS: These findings taken together suggest that poor prognosis of colorectal cancer in patients over 80 years is associated with down-regulation of mRNA expression of some tumor suppressor genes.     

Colon and rectal cancer in the elderly. High incidence of asymptomatic disease, less surgical emergencies, and a favorable short-term outcome

BACKGROUND: This is a retrospective study aimed to report short-term outcome among patients age > or =70 years surgically treated for colorectal cancer. METHODS: All patients with the discharge diagnosis of colon and rectal cancer at St. Louis University Hospital from 1992 to 2002 were reviewed. Patients were assessed as to demographics, presenting symptoms, therapy, surgical morbidity and mortality. RESULTS: One hundred eighty-one patients age > or =70 years with colorectal cancer were identified. The mean age was 78 years; 107/181 (59%) were females. Rectal bleeding and change in bowel habits were the most common presenting symptoms. Fifty-four out of 181 (30%) were asymptomatic at diagnosis. The diagnosis was made by colonoscopy in 75% of the patients. One hundred forty-three out of 181 (79%) had colon cancer; 38/181 (21%) had rectal cancer. Fourteen out of 181 (8%) did not undergo surgery. Twenty-two out of 181 (12%) were operated on as a surgical emergency. ASA classification was I-II in 52%, III in 34%, and IV-V in 14%. Nineteen out of 38 (50%) with rectal cancer underwent a sphincter-preserving procedure. Overall, there was a 29% major morbidity from surgery. Thirty-day mortality was 11% (21 deaths). Only the development of a postoperative complication predicted mortality. CONCLUSIONS: Elderly patients tolerate surgery well for colon and rectal cancer in the short-term. Many patients are asymptomatic at diagnosis. Surgical emergencies are few and patients have a favorable stage of disease. This data supports aggressive detection of colorectal cancer in asymptomatic elderly patients who may harbor occult colorectal cancer.     

Esophagectomy in patients aged over 80 years with esophageal cancer

BACKGROUND/AIMS: Esophagectomy for esophageal cancer is one of the most invasive surgical procedures. However, with the recent aging of the population, clinicians are increasingly encountering patients with advanced age (over 80 years) who require treatment for esophageal cancer. Patients in this age group tend to be regarded as at high risk in terms of surgical treatment. In the present study, the authors examined perioperative complications and clinical outcome in esophagectomy in patients aged over 80 years compared with those aged 70-79 and discuss the risk and appropriateness of esophagectomy in the older group. METHODOLOGY: Of patients with esophageal cancer at our institute, 25 were aged over 80 years, while 95 were aged 70-79 years. We statistically compared those who underwent esophagectomy; 8 in the older group and 62 in the younger group. The oldest patient was an 84-year-old man. Among the 8 older patients, 7 were male and 1 was female. All cases were histologically confirmed as squamous cell carcinoma and this series included 1 case in Stage 0, 3 in Stage I and 4 in Stage III. Total thoracic esophagectomy was performed in 5 patients, transhiatal blunt dissection in 2 and lower thoracic esophagectomy in 1. RESULTS: Rate of surgical treatment was significantly lower in the older group than in the younger group (32.0% vs. 65.3%, p < 0.001). No significant difference was observed in postoperative complications or mortality. Regarding clinical postoperative outcome in the older group, there were 5 deaths: 1 related to surgery, 2 to other causes (at 5 and 12 months), 2 to cancer (4 and 11 months). The remaining patients were alive at 31, 60, and 88 months. No significant difference was observed in overall or disease specific survival after surgery between the 2 groups. CONCLUSION: No statistically significant differences were apparent in morbidity, mortality or clinical outcome in the 2 groups. Since surgery seems to confer similar symptomatic improvements and survival in patients aged over 80 to those expected for patients aged 70-79, we believe that surgeons should not withhold esophagectomy in patients aged over 80 years because of advanced age alone.     

Different occurrence of CD8+, CD45R0+, and CD68+ immune cells in regional lymph node metastases from colorectal cancer as potential prognostic predictors

BACKGROUND AND AIMS: To study whether there are differences in the immunohistochemical staining of CD8, CD45R0, and CD68 of immune cells in regional lymph node metastases from colorectal cancer that are of potential interest in prognostic prediction. MATERIALS AND METHODS: Analysis of archival specimens from 93 patients operated on for colorectal cancer (based on monoclonal antibodies, the ABC technique, and semiquantitative classification). RESULTS: There was a significant difference in survival time between patients with respect to the number of positive immune cells. The cancer-specific 5-year survival rate was 77% for patients with high numbers of CD8+ cells, compared to 33% for those with lower numbers. The corresponding figures for patients with CD45R0+ cells were 66% vs. 33%, and for patients with CD68+ cells 60% vs. 38%. Significant differences remained among the 74 patients without adjuvant radio/chemotherapy regarding CD8 and CD45R0 but not CD68. CONCLUSION: The presence of CD8+, CD45R0+, and CD68+ immune cells in regional lymph node metastases may serve as predictors of patients survival in colorectal cancer Dukes' stage C.     

Abdominoperineal resection for rectal cancer at a specialty center

PURPOSE: Although sphincter-preservation procedures have replaced abdominoperineal resection as the treatment of choice for rectal cancer, a subset of patients with rectal cancer will still require abdominoperineal resection. The use of adjuvant radiotherapy has been shown to reduce local recurrence, and combined modality therapy (chemoradiation) improves survival. Sharp mesorectal excision compared with the classic teaching of blunt retrorectal dissection is also an important component of local control. The primary aim of the present study was to evaluate the postoperative complications associated with neoadjuvant therapy in patients requiring complete rectal excision. Oncologic outcomes for all patients with abdominoperineal resection are also provided. METHODS: A prospective database of 5,634 patients who underwent surgery for colorectal cancer at Memorial Sloan-Kettering Cancer Center between the years 1987 and 1997 was reviewed. Patients with primary adenocarcinoma of the rectum who underwent abdominoperineal resection were identified. In 1,622 patients who were operated on for primary rectal cancer, 292 patients (18 percent) underwent abdominoperineal resection and the rest had a sphincter-preserving procedure. Ten patients were excluded from the study because of prior pelvic irradiation for other cancer (8 patients) and insufficient radiation dose (<4,000 cGy; 2 patients). Neoadjuvant radiotherapy was given to 123 patients and postoperative adjuvant radiotherapy to 65 patients, whereas 94 did not receive radiotherapy. Intraoperative radiotherapy combined with preoperative radiotherapy was administered to 23 of the 123 patients given neoadjuvant radiotherapy. RESULTS: The duration of the operation was significantly longer in both neoadjuvant radiotherapy and intraoperative radiotherapy groups compared with the nonradiotherapy group (P = 0.01 and P < 0.0001, respectively). Estimated blood loss, mean number of blood units transfused per patient, and the percentage of patients being transfused were similar among the groups. Early postoperative complications were significantly higher in the neoadjuvant radiotherapy groups compared with the nonradiotherapy group. Late complications, overall survival, disease-free survival, and local recurrence were not significantly different among the groups. CONCLUSIONS: In patients with cancer of the lower one-third of the rectum, sharp pelvic dissection can result in a low rate of local recurrence even without radiotherapy. The role of preoperative radiotherapy, although associated with higher perineal wound complications, is important in increasing resectability and sphincter-preservation rate. Randomized, prospective trials will be needed to establish the role of adjuvant radiotherapy in patients undergoing sharp mesorectal excision for rectal cancer.     

Carcinoembryonic antigen and patterns of recurrence after curative resection of the colorectal cancer

BACKGROUND/AIMS: The influence of carcinoembryonic antigen (CEA) on patterns of recurrence after curative surgery in colorectal cancer was uncertain. We investigated the differences in the patterns of recurrence between the patients with elevated and normal preoperative serum CEA level. METHODOLOGY: A retrospective study was performed in 384 patients with primary colorectal adenocarcinoma of Dukes' classification A to C. RESULTS: In Dukes' C2 rectal cancer, hepatic and local recurrence rates were higher in the patients with >10 ng/mL of CEA than those were in the patients with < or = 5 ng/mL of CEA (p=0.028, p=0.049, respectively). Time to recurrence at lung was earlier in the patients with > 10 ng/mL of CEA than that was in the patients with < or = 5 ng/mL of CEA (p=0.0008). CONCLUSIONS: In Dukes' C2 rectal cancer patients with elevated preoperative serum CEA level, new options for adjuvant therapy should be evaluated as 1st line of therapy and special attention should be given to recurrence in liver during the early postoperative surveillance.