Synchronous resection of colorectal primary and hepatic metastasis

Up to 50% of the over 140,000 new colorectal cancer patients will present with synchronous colorectal cancer and liver metastasis. Surgical management of patients with resectable synchronous colorectal hepatic metastasis is complex and must consider multiple factors, including the presence of symptoms, location of primary tumor and liver metastases, extent of tumor (both primary and metastatic), patient performance status, and underlying comorbidities. Possible approaches to this select group of patients have included a synchronous resection of the colorectal primary and the hepatic metastases or a staged resection approach. The available literature regarding the safety of synchronous versus staged approaches confirms that a simultaneous resection may be performed in selected patients with acceptable morbidity and mortality. Perioperative mortality when minor hepatectomies are combined with colorectal resection is consistently ≤5%. Perioperative morbidity varies considerably following both synchronous and staged resections. However, the bulk of the existing literature confirms that simultaneous resections are both feasible and safe when hepatic resections are limited to <3 segments. Data regarding the oncologic outcomes following synchronous versus staged resections for Stage IV colorectal cancer are more limited than those available regarding postoperative morbidity and mortality. The available data suggest equivalent overall and disease-free survival regardless of timing of resection. Experience with minimally invasive combined colorectal and hepatic resections is extremely limited to date and consists exclusively of small single center series. The potential benefits of a minimally invasive approach will await the results of larger studies.Key Words: Colorectal cancer, colorectal liver metastases, synchronous resection     

Resection of hepatic and pulmonary metastases in patients with colorectal cancer.

The resection of liver and lung metastases is now regarded as valid therapy, although the surgical procedure of both metastatic sites has not been clearly defined. Nine consecutive patients who underwent resection of both liver and lung metastases from colorectal cancer (5 Dukes' stage B, 3 C, 1 D) between 1986 and 1999 were studied retrospectively. A total of 19 resections were performed: 8 hepatectomies, 2 liver wedge resections, and 9 lung lobectomies. No operative or hospital deaths occurred, and mean postoperative hospital stay per procedure was 12 days. Mean survival after resection of the primary colorectal tumor was 66.3 (range: 26-96) months. The median interval was 24.2 (range: 2-39) months from resection of the liver metastasis and 30.4 (range: 3-45) months from resection of the lung metastasis. At the last follow-up, 6 patients were still alive, 4 of whom were free of recurrence 59, 69, 74, and 76 months, respectively, after resections. Three patients died with metastases. Aggressive treatment of liver and lung secondaries from colorectal cancer was performed without hospital mortality and acceptable morbidity. Longer survival times warrant the use of this alternative therapy for selected patients. In association with new effective chemotherapies, it will be possible to select patients who will benefit from surgery.     

Thermal tumor ablation therapy for colorectal cancer hepatic metastasis

Surgical resection for colorectal hepatic metastases (CRHM) is the preferred treatment for suitable candidates, and the only potentially curative modality. However, due to various limitations, the majority of patients with CRHM are not candidates for liver resection. In recent years, there has been an increasing interest in the role of thermal tumor ablation (TTA) as a component of combined resection-ablation strategies, staged hepatic resections, or as standalone adjunct treatment for patients with CRHM. Thus, ablative approaches have expanded the group of patients with CRHM that may benefit from liver-directed treatment strategies.Key Words: Colorectal liver metastasis, tumor ablation, thermal ablation     

Liver resection for metastatic non-colorectal non-neuroendocrine hepatic neoplasms.

AIMS: Major liver surgery can be performed safely and hepatic resection for metastatic disease is increasingly carried out. However, the role of liver resection for hepatic metastases from non-colorectal, non-neuroendocrine (NCNN) cancers is unknown. Our aim was to evaluate our experience from hepatectomies for NCNN metastases. A retrospective study of 170 patients with liver resection performed the last 8 years was performed in two liver units in affiliated university hospitals. METHODS: Eighteen patients underwent liver resection for NCNN tumours. Origins included kidney (n=6), breast (n=4), gastric tumours (n=4), intestinal leiomyosarcoma (n=2) and malignant melanoma and in one patient a metastatic papillary of unknown origin was found. Eleven patients underwent a hepatic lobectomy and seven had local resections. Ten hepatectomies were performed at the same time with the primary tumour resection (synchronous resections) with five of those in an en bloc fashion with the primary tumour. RESULTS: There were no post-operative deaths and the peri-operative morbidity was minimal. During a median follow-up time of 3.2 years, 14 patients are alive with one of them having developed pulmonary metastases. CONCLUSION: In carefully selected patients with NCNN liver metastasis, liver resection can prolong survival as well and improve quality of life. Copyright Harcourt Publishers Limited.     

Pulmonary metastasectomy: might the type of resection affect survival?

BACKGROUND AND OBJECTIVES: Metastasectomy proved to be the choice treatment in the case of pulmonary metastasis. In this study we assessed the impact on survival of three types of resection: minimal by laser or conventional device and lobectomy. METHODS: We considered 85 patients who underwent lung metastasectomy for tumors that originated from various sites. Fifty-two minimal resections were accomplished in 34 patients by conventional (diathermy dissection or stapler suture line) device, 59 resections in 29 by Nd:YAG laser. Lobectomies were 22. Minimum follow up required was 2 years. RESULTS: The 3-year Kaplan-Meier survival rate was 63%, 44%, 53% for laser, conventional resections and lobectomy. The 5-year survival was 40%, 28%, 26% respectively. Among the groups there was no significant difference (P = 0.15). Laser patients showed shorter periods of air leakage and hospital stay. CONCLUSIONS: The type of resection did not disclose statistically significant differences on survival. Minimal surgery, especially by laser device, is recommended for less morbidity.     

Surgical treatment of early gastric carcinoma

From January 1965 until December 1982, early gastric carcinoma cases comprised 765 of 2,235 curative resections and 17 of 620 noncurative resections, for a total of 782 cases. The rate of lymph node metastasis for mucosal carcinoma was 1.2%, and that for submucosal carcinoma was 18.2%. Gastrectomy with removal of the second-group lymph node proved adequate for submucosal carcinoma. The five-year survival rates for mucosal carcinoma and for submucosal carcinoma were 94.9% and 93.6% respectively. The rate of recurrence of mucosal carcinoma was 0.6%, against 2.5% for submucosal carcinoma. Adjuvant chemotherapy is necessary to obtain improved surgical results for submucosal carcinoma. Important factors affecting the recurrence of submucosal carcinoma are lymph node metastasis, macroscopic findings and histological findings. Ten out of 17 cases of noncurative resection had cancer cells at the resection margin, caused by inadequate resection.     

Intraoperative peritoneal lavage cytology offers prognostic significance for gastric cancer patients with curative resection

Outcomes of patients with gastric cancer who exhibit positive peritoneal lavage cytology findings (CY⁺) vary by diagnostic methods because of quantitative and qualitative cancer cell diversity. This study sought to establish practical diagnostic criteria for performing curative resections, based on peritoneal lavage cytology findings in gastric cancer patients. We enrolled 1028 patients with gastric cancer who underwent R0/1 (n = 911) or R2 (n = 117) resections and analyzed relationships between cancer cell findings in peritoneal lavage fluid and clinicopathological factors in the R0/1 group. We found 68 patients with CY⁺ status. Receiver operating characteristic analyses and multivariate analyses showed that the presence of ≥1 signet ring cell, ≥5 cell clusters or ≥50 isolated cancer cells in peritoneal lavage fluid predicted poor prognoses in the 68 CY⁺ patients. High‐risk CY⁺ group patients with at least one of the above predictors had the highest hazard ratio (HR = 3.28, P < 0.001). The remaining (low‐risk) patients had a survival curve similar to that of patients with a normal cytology. The high‐risk CY⁺ patients who underwent R1 resection had poor prognoses despite no macroscopic peritoneal metastasis (2% 5‐year survival)—equivalent to that of patients who underwent R2 resection. The CY⁺ criteria defined in this study could help identify candidates for curative resection as an initial therapy for gastric cancer.     

Safety of Simultaneous Bowel and Liver Resections for Colon and Rectal Cancer

The synchronous presentation of primary colorectal cancer and colorectal liver metastasis (CLM) occurs in 23-51 % of all colorectal cancer patients at the time of diagnosis. The optimal treatment of patients with synchronous primary colorectal cancer and CLM has been controversial for decades. Here, the available literature regarding staged versus simultaneous resection of synchronous CLM is reviewed in terms of the perioperative and prognostic outcomes. Recent studies support the safety of a simultaneous approach for the resection of synchronous CLM, demonstrating an equivalent or better short-term outcome compared with a staged approach. The postoperative mortality following either simultaneous or staged resections is reportedly less than 5 %. The long-term prognosis following a simultaneous approach is comparable to that following a staged approach. Most series have demonstrated equivalent overall and disease-free survival periods, regardless of the timing of the resections. An increased perioperative risk following simultaneous major hepatectomies, compared with minor resections, was proposed by several authors. In addition, the operative procedures for multiple liver metastases have changed over time toward a parenchymal-sparing approach, providing better prognostic outcomes than major hepatectomies. The available evidence indicates that comparable short-term as well as long-term outcomes can be expected regardless of a staged or simultaneous resection of synchronous CLM. However, minor resections of colorectal liver metastases can reduce the perioperative risks, providing room for a repeated treatment approach.     

Laparoscopic synchronous resection of colorectal cancer and liver metastases: A systematic review

While colorectal and hepatic resections are commonly performed through a laparoscopic approach, the safety and feasibility of total laparoscopic synchronous resections (LSR) of colorectal liver metastasis (CRLM) have not been established. In this systematic review, short- and long-term outcomes were comparable for patients undergoing LSR and open synchronous resection. LSR was safe and feasible for patients with synchronous CRLM and should be considered in well-selected patients.     

The extent of resection influences outcome following hepatectomy for colorectal liver metastases.

BACKGROUND: The acceptable indications for liver resection in patients with colorectal metastases have increased significantly in the last decade. It is thus becoming more difficult to ascertain the limitations for selection as the boundaries have been greatly extended. This has resulted in not only more extensive resections, but more atypical and bilobar resections. The aim of this study was to compare the outcome of patients undergoing different extent of liver resection in a specialist unit. METHODS: All patients undergoing liver resection for colorectal metastases at the Royal Infirmary of Edinburgh between October 1988 and April 2001 were reviewed. Patients were allocated into one of three groups: standard group, extended group, and segmental group. Patient information was collected from a prospectively completed database. RESULTS: One hundred and thirty-seven patients had liver resections for colorectal metastases during the study period. There were 69 standard hepatectomies, 41 extended resections and 27 segmental resections. CEA level was significantly lower in the segmental group(p = 0.012). There was a significant difference between the groups in terms of median operating time (p < 0.0001, Kruskal-Wallis test), operative blood loss (p = 0.006, Kruskal-Wallis test) and post-operative stay ( p = 0.036, Kruskal-Wallis test). Major post-operative complications were similar between standard and extended resections but less following segmental resection (p = 0.050. Predicted median survival was 51 months following standard resection, 23 months following extended resection and 59 months after segmental resection ( p = 0.037, log rank test), however, there was no difference between the three groups for actual 5-year survival (p = 0.662, Pearson chi-square test). CONCLUSION: Morbidity and mortality rates were comparable with other previous studies as was overall survival, although survival in patients undergoing extended resections was reduced. There was an acceptable level of morbidity and mortality for all three groups. Patients undergoing segmental resection had fewer complications, shorter length of stay, and the longest median survival suggesting adequate oncological clearance. Segmental resection has a role for favourably placed tumour deposits if oncological clearance can be ensured. Extended liver resections have a role for selected patients with bilobar colorectal metastases or large solitary deposits close to the hepatic vein confluence.     

Clinical outcomes for patients with soft tissue sarcoma of the hand

BACKGROUND:

In an earlier report from the current study center regarding surgical treatment for patients with soft tissue sarcoma (STS) of the hand, it was concluded that repeat resection or amputation improves outcomes. Since then, the authors have aggressively sought to achieve negative resection margins, using standard or modified amputations when needed, and performing repeat resections to negative surgical margins when they were not achieved at the time of initial surgery. The current review was conducted to determine whether this approach resulted in better outcomes.

METHODS:

A retrospective review of 53 patients with STS of the hand who were treated between 1996 and 2005 was performed. Recurrence‐free survival (RFS) and functional outcome of hand‐preserving procedures were assessed according to the Musculoskeletal Tumor Society (MSTS) system.

RESULTS:

The median RFS was not reached at the time of last follow‐up. Of 53 patients, 6 (11%) had positive microscopic resection margins. Three patients underwent repeat resection to negative surgical margins, whereas another 3 patients did not. All 3 patients with positive microscopic surgical margins that were not re‐excised developed local disease recurrence; 2 patients also developed distant metastases. Two of the 50 patients with negative resection margins developed distant metastases. All 5 patients who developed local and/or distant disease recurrence had deep tumors. The median MSTS score was 29 (interquartile range, 27‐30). Patients who underwent more extensive resections, such as double ray amputations, had lower MSTS scores.

CONCLUSIONS:

Suboptimal biopsies and positive resection margins are associated with local and distant disease recurrence in patients with STS. The results of the current study suggest that aggressive surgical treatment can result in better clinical outcomes, and underscore that care must be taken when planning biopsies of hand tumors. Cancer 2011. © 2010 American Cancer Society.     

Repeated resections for originally unresectable liver metastasis from colorectal cancer after multiagent chemotherapy

We describe the case of a 74-year-old man with liver resection for originally unresectable liver metastasis from colorectal cancer after multiagent chemotherapy. Eleven bilobar liver metastases appeared four months after curative resection for double cancer of sigmoid colon and upper rectum. After 6 courses of multiagent chemotherapy (mFOLFOX 6 with bevacizumab), the number of liver metastasis decreased from 11 to 5. The patient underwent curative resection for liver metastasis. A new lesion of 7 mm in the segment 6 appeared 8 months after an initial liver resection. After 3 months' observation, two more liver metastases appeared. All liver metastases were resected. Solitary lung metastasis appeared 10 months after the second liver resection. The lung metastasis was also resected. The patient was alive with no evidence of disease in 33 months after the initial liver resection. We experienced the case with repeated liver resections after multiagent chemotherapy for originally unresectable bilobar liver metastasis. The therapeutic strategy which combines surgical resection with cytotoxic chemotherapy will be important more than ever.     

Leiomyosarcoma of the gastrointestinal tract: Should we consider metastasis to regional lymph nodes?

About one third of leiomyosarcomas of the gastrointestinal tract do develop metastasis; and nearly 90% of the metastasis are intra-abdominal. It is said that leiomyosarcoma rarely involves regional nodes, although two series reported 8% of leiomyosarcomas of the stomach and 7% of the small intestines had nodal metastasis at initial operations (mostly of limited resections). It is suggested that wider resection of primary tumor with adjacent mesentery may reveal higher frequency of occult nodal metastasis and might prevent some of the loco-regional relapse and sarcomatosis.     

Evaluation of hepatic resection for metachronous liver metastases from gastric cancer

To evaluate the effect of hepatic resection for metachronous liver metastases after resection of gastric cancer, the clinicopathological factors of gastric cancer, state of liver metastasis, surgical procedures for liver metastasis, and remote survival were studied. Between 1989 and 2001, 30 consecutive patients underwent hepatic resections (36 resections) for metachronous liver metastases. The patients included 25 men and 5 women, and the median age was 60 years old (range 46-86 years old). As for curability, curative A/curative B was 10/20, and H0/H1/H2 was 25/3/2. The mean period from initial surgery to the liver resection was 19.3 months (range 6.3-65.2 months), and the liver metastatic conditions were H1 for 27 patients and H2 for 9 patients. By number of liver metastases, 27 patients had 1 lesion, 24 patients had 2, and 5 patients had more than 3 lesions. Twenty-nine patients were negative and 7 were positive for lymph node metastasis. A partial resection was performed for 13 patients, a subsegmentectomy for 3 patients, a segmentectomy for 7 patients, a lobectomy for 8 patients, and an extended lobectomy for 5 patients. For all patients except those who had other causes of death, the overall mean survival time was 702 days and the 5-year survival rate was 26.4%. There were four 5-year survivors after hepatic resection. In conclusion, the main prognostic factor after resection of metachronous liver metastases was the existence of lymph node metastasis, and the remote survival of patients with abdominal para-aortic lymph node recurrence was poor. The type of liver resection was not a predictor of survival. The resection of liver recurrence was evaluated clinically, but we should maintain strict criteria and select adequate surgical procedures.     

Studies on the results of operations for carcinoma of the sigmoid colon

Of 734 patients with colorectal cancer operated on during the past 21 years, 142 had carcinoma of the sigmoid colon. Curative resections were performed in 103 patients and non-curative resections in 22, the resection rate being 88.0%. Among 103 patients with curative resection, resection of the sigmoid colon was performed in 79, and their 5-year survival rate was 84.6%. Eight patients died within 5 years due to recurrence. Many of them had the constricting type macroscopically and Dukes C with positive lymph node metastasis. Therefore, in such cases, resection of the sigmoid colon with extended lymph node dissection or left hemicolectomy should be performed.     

Value of routine intraoperative frozen sections of proximal bile duct margins in perihilar cholangiocarcinoma,a retrospective multicenter and matched case-control study

BackgroundCurrently, the potential benefits of additional resection after positive proximal intraoperative frozen sections (IFS) in perihilar cholangiocarcinoma (pCCA) on residual disease and oncological outcome remain uncertain. Therefore, the aim of this study is to investigate the number of R0 resections after additional resection of a positive proximal IFS and the influence of additional resections on overall survival (OS) in patients with pCCA.Materials and methodsA retrospective, multicenter, matched case-control study was performed, including patients undergoing resection for pCCA between 2000 and 2019 at three tertiary centers. Primary outcome was the number of achieved ‘additional’ R0 resections. Secondary outcomes were OS, recurrence, severe morbidity and mortality.ResultsForty-four out of 328 patients undergoing resection for pCCA had a positive proximal IFS. An additional resection was performed in 35 out of 44 (79.5%) patients, which was negative in 24 (68.6%) patients. Nevertheless, seven out of these 24 patients were eventually classified as R1 resection due to other positive resection margins. Therefore, 17 (48.6%) patients could be classified as “true” R0 resection after additional resection. Ninety-day mortality after R1 resections was high (25%) and strongly influenced OS. After correction for 90-day mortality, median OS after negative additional resection was 33 months (95%CI:29.5–36.5) compared to 30 months (95%CI:24.4–35.6) after initial R1 (P = 0.875) and 46 months (95%CI:32.7–59.3) after initial R0 (P = 0.348).ConclusionThere were only 17 patients (out of a total of 328 patients) that potentially benefitted from routine IFS. Additional resection for a positive IFS leading to R0 resection was not associated with improved long-term survival.     

Liver resection for intrahepatic cholangiocarcinoma

AIMS AND BACKGROUND: Intrahepatic cholangiocarcinoma (IHCC) is the second most common primary liver cancer, representing 10% of all primary liver malignancies. Despite the increase in its incidence, this tumor remains extremely rare in Western countries and few reports detailing experience with surgical resection have been published. The aim of this study was to analyze the experience with resection of IHCC in our center. METHODS: From 1987 to 2003 we observed 35 patients with IHCC; 15 of them (42.8%) were submitted to hepatic resection. IHCCs accounted for 13% of all liver resections for primary liver tumors carried out at our center during this period. According to the classification of the Liver Cancer Study Group of Japan, the tumors were classified as "mass-forming" in 14 cases and as "periductal" in one case. Major resections were performed in ten cases and minor resections in five cases. In the patient with a periductal tumor a major resection was performed along with excision of the main biliary confluence. In 14 cases (93.3%) tumor-free resection margins were obtained. RESULTS: The intraoperative mortality was nil and the postoperative mortality 6.6%. The postoperative morbidity rate was 21.4%. The mean overall survival was 38.4 months, with 86% and 49% one- and three-year survival rates, respectively. Patients with mass-forming tumors and curative resections (R0) (mean survival 40.8 months; one- and three-year survival rates 92.3% and 52.7%), and those with TNM stage I-II tumors (mean survival 43.7 months; one- and three-year survival rates 100% and 66.7%) had a longer survival. The patient with the periductal tumor and R1 resection died after seven months. CONCLUSIONS: These results support a surgical approach based on accurate selection of patients with IHCC and aimed at radical resection whenever possible. The good survival rates observed in R0 resections emphasize the role of radical surgery as the only chance of cure for patients with this tumor.     

Beyond Margin Status: Population-Based Validation of the Proposed International Association for the Study of Lung Cancer Residual Tumor Classification Recategorization

IntroductionThe International Association for the Study of Lung Cancer’s (IASLC’s) proposal to recategorize the residual tumor (R) classification for resected NSCLC needs validation.MethodsUsing a 2009 to 2019 population-based multi-institutional NSCLC resection cohort from the United States, we classified resections by Union for International Cancer Control (UICC) and IASLC R criteria and compared the distribution of R classification variables and their survival associations.ResultsOf 3361 resections, 95.3% were R0, 4.3% were R1, and 0.4% were R2 by UICC criteria; 33.3% were R0, 60.8% were R-uncertain, and 5.8% were R1/2 by IASLC criteria; 2044 patients (63.8%) migrated from UICC R0 to IASLC R-uncertain. Median survival was not reached, 69 (95% confidence interval [CI]: 64–77), and 25 (95% CI: 18–36) months, respectively, for patients with IASLC R0, R-uncertain, and R1 or R2 resections. Failure to achieve nodal dissection criteria caused 98% of migration to R-uncertainty, metastasis to the highest mediastinal node station, 5.8%. Compared with R0, R-uncertain resections with mediastinal nodes, no mediastinal nodes, and no nodes had adjusted hazard ratios of 1.28 (95% CI: 1.10–1.48), 1.47 (95% CI: 1.24–1.74), and 1.74 (95% CI: 1.37–2.21), respectively, suggesting a dose-response relationship between nodal R-uncertainty and survival. Accounting for mediastinal nodal involvement, the highest mediastinal station involvement was not independently prognostic. The incomplete resection variables were uniformly prognostic.ConclusionsThe proposed R classification recategorization variables were mostly prognostic, except the highest mediastinal nodal station involvement. Further categorization of R-uncertainty by severity of nodal quality deficit should be considered.     

An estimate of risk of malignancy for a benign diagnosis in thyroid fine‐needle aspirates

BACKGROUND:

The risk of malignancy for a benign diagnosis in a thyroid fine‐needle aspiration is controversial because of lack of histologic follow‐up.

METHODS:

The author reviewed the results of all thyroid aspirations with surgical resection performed during the past 13 years at Baptist Hospital of Miami and Homestead Hospital, Homestead, Florida, combined these procedures with those in the literature, and correlated risk of malignancy with percentage of biopsies performed.

RESULTS:

A total of 7089 aspirations and 1331 resections were performed. In the literature, the percentage of all benign cases that underwent resection ranged from 3% to 41%. Risk of malignancy decreased with an increased percentage of resections. The risk of malignancy for series with <8% of all benign aspirates resected was significantly higher than the risk for series with ≥8% of cases biopsied (15.1% vs 5.9%, P = .02). Logarithmic and linear estimates of risk of malignancy if 100% of cases were biopsied were 3% and 2.5%.

CONCLUSIONS:

The best estimate of the risk of malignancy for a benign diagnosis in a thyroid fine‐needle aspiration is 2.5%‐3%. This level of risk is affected by the percentage of benign cases that are resected. Cancer (Cancer Cytopathol) 2010. © 2010 American Cancer Society.     

An evolution of clinical application of inferior pedicle based rectus abdominis myocutaneous flap for repair of perineal defects after radical surgery for cancer

The inferior epigastric artery based rectus abdominis myocutaneous flap (RAMF) is one of the most versatile flaps used to bridge gaps in the perineum and groin, in the reconstruction of vagina after radical resections for cancer and in selected patients with benign and non‐healing perineal lesions. Its use for reconstruction after Abdomino‐perineal resection was first described in 1984. This review attempts to summarize the anatomic‐technical aspects of inferiorly based RAMF and its applications. J. Surg. Oncol. 2010;102:287–294. © 2010 Wiley‐Liss, Inc.