Postoperative retroperitoneal desmoid tumor mimics recurrent gastrointestinal stromal tumor: A case report

Desmoid tumor is a locally invasive, myofibroblastic, nonmetastatic tumor. Its pathogenesis remains unclear and it may involve genetic abnormalities, sex hormones and traumatic injury, including surgery. Postoperative intra-abdominal desmoid tumor is rare, especially in the retroperitoneum. We report a case of postoperative retroperitoneal desmoid tumor that developed 29 mo after the first excision of a gastrointestinal stromal tumor. Sporadic trauma-related intra-abdominal desmoid tumors reported in the English literature are also reviewed. Despite an extremely low incidence, postoperative desmoid tumor should be considered in the differential diagnosis when a recurrent neoplasm is found at least one year after operation. However, it is a clinical challenge to distinguish recurrent malignant neoplasms from desmoid tumors, and surgical resection is the treatment option depending on the anatomic location.     

Pulmonary resection for metastases from colorectal cancer: prognostic factors and survival

Backgrounds Pulmonary metastases occur in up to 10% of all patients who undergo curative resection. Surgical resection is an important part in the treatment of pulmonary metastasis from colorectal cancer. We analyzed the treatment outcome and prognostic factors affecting survival in this subset of patients. Materials and methods Between October 1994 and December 2004, 59 patients underwent curative resection for pulmonary metastases of colorectal cancer. Uncontrollable synchronous liver and lung metastasis or synchronous colorectal cancer with isolated lung metastasis were excluded from this study. A retrospective review of patient characteristics and factors influencing survival was performed. Survival was analyzed by the Kaplan–Meier method. Comparison between groups were performed by a log-rank analysis and the Cox proportional hazard model. Results The 5-year overall survival rate of all patients who received pulmonary resection was 50.3%. The number of pulmonary metastases was significantly related with survival in univariate analysis, but not in multivariate analysis (p = 0.032). Prethoracotomy carcinoembryonic antigen (CEA) level exceeding 5 ng/ml was related with poor survival (p = 0.001). A disease-free interval of greater than 2 years did not correlate with survival after thoracotomy (p = 0.3). Conclusion The prethoracotomy CEA level and the number of metastases were independent prognostic factors. Resection of pulmonary metastasis from colorectal cancer may result in improved survival or even healing in selected patients. Pulmonary resection of colorectal cancer is regarded as a safe and effective treatment with low morbidity and mortality rates.     

结直肠癌局部复发的外科治疗

结直肠癌手术后局部复发的原因不仅与肿瘤的生物学特性有关,更重要的是与术者的手术技术,手术理念和手术操作以及是否采用综合治疗有直接的关系。局部复发要力求早期发现,根据复发的类型采用不同的手术方式和治疗策略,进而使患者获得最大收益。     

Current role of hyperthermic intraperitoneal chemotherapy in the treatment of peritoneal carcinomatosis from colorectal cancer

Peritoneal carcinomatosis is one of the most common routes of dissemination of colorectal cancer (CRC). It is encountered in 7% of patients at primary surgery, while it develops in about 4% to 19% of patients after curative surgery and in up to 44% of patients with recurrent CRC. Peritoneal involvement from colorectal malignancies has been considered traditionally as a manifestation of terminal disease, due to limited response to conventional surgical and chemotherapeutic treatments. In the past few years t...     

Personalized surgical management of colorectal cancer in elderly population

Colorectal cancer(CRC)in the elderly is extremely common but only a few clinicians are familiar with the complexity of issues which present in the geriatric population.In this phase of the life cycle,treatment is frequently suboptimal.Despite the fact that,nowadays,older people tend to be healthier than in previous generations,surgical undertreatment is frequently encountered.On the other hand,surgical overtreatment in the vulnerable or frail patient can lead to unacceptable postoperative outcomes with high mortality or persistent disability.Unfortunately,due to the geriatric patient being traditionally excluded from randomized controlled trials for a variety of factors(heterogeneity,frailty,etc.),there is a dearth of evidence-based clinical guidelines for the management of these patients.The objective of this review was to summarize the most relevant clinical studies available in order to assist clinicians in the management of CRC in the elderly.More than in any other patient group,both surgical and non-surgical management strategies should be carefully individualized in the elderly population affected by CRC.Although cure and sphincter preservation are the primary goals,many other variables need to be taken into account,such as maintenance of cognitive status,independence,life expectancy and quality of life.     

Evolving management of colorectal cancer

This article reviews recent advances in surgical techniques and adjuvant therapies for colorectal cancer, including total mesorectal excision, the resection of liver and lung metastasis and advances in chemoradiation and foreshadows some interventions that may lie just beyond the frontier. In particular, little is known about the intracellular and extracellular cascades that may influence colorectal cancer cell adhesion and metastasis. Although the phosphorylation of focal adhesion kinases and focal adhesion associated proteins in response to integrin-mediated cell matrix binding （“outside in integrin signaling” is well described, the stimulation of cell adhesion by intracellular signals activated by pressure prior to adhesion represents a different signal paradigm. However, several studies have suggested that increased pressure and shear stress activate cancer cell adhesion. Further studies of the pathways that regulate integrin-driven cancer cell adhesion may identify ways to disrupt these signals or block integrin-mediated adhesion so that adhesion and eventual metastasis can be prevented in the future.     

Surgical management of 143 patients with adult primary retroperitoneal tumor

AIM: To analyze the surgical management of adult primary retroperitoneal tumors (APRT) and the factors influencing the outcome after operation. METHODS: Data of 143 cases of APRT from 1990 to 2003 in the First Affiliated Hospital of China Medical University were evaluated retrospectively. RESULTS: A total of 143 cases of APRT were treated surgically. Among them, 122 (85.3%) underwent complete resection, 16 (11.2%) incomplete resection, and 3 (3%) surgical biopsies. Twenty-nine (20.2%) underwent tumor resection plus multiple organ resections. Ninety-five malignant cases were followed up for 1 mo to 5 years. The 1-year, 3-year, and 5-year survival rates of the patients subject to complete resection was 94.9%, 76.6% and 34.3% and that of patients with incomplete resection was 80.4%, 6.7%, and 0%, respectively (P < 0.001). The Cox multi-various regression analysis showed the completeness of tumor, sex and histological type were associated closely with local recurrence. CONCLUSION: Sufficient preoperative preparation and complete tumor resection play important roles in reducing recurrence and improving survival.     

Effect of perioperative blood transfusions on recurrence of colorectal cancer

PURPOSE: This study was undertaken to evaluate the influence of perioperative blood transfusions on colorectal cancer recurrence. METHODS: All articles published up to December 1996 in English (or with an English abstract) were retrieved, both using MEDLINE and scanning their references, to be considered for this meta-analysis. RESULTS: One hundred thirty-one articles were identified, and 99 of them were excluded because they analyzed survival or mortality, were repetitive publications, or were reviews or letters. Thirty-two original studies (9 were prospective) on 11,071 patients were included for further analysis; 20 showed a detrimental effect of perioperative blood transfusions. Nineteen articles used also multivariable techniques, and 11 found perioperative blood transfusions to be an independent prognostic factor. Pooled estimates of the effect of perioperative blood transfusions on colorectal cancer recurrence yielded an overall odds ratio of 1.68 (95 percent confidence interval, 1.54–1.83) and a rate difference of 0.13 (95 percent confidence interval, 0.09–0.17) against patients who received transfusions. Stratified meta-analyses also confirmed these findings when stratifying patients by site and stage of disease. The effect of perioperative blood transfusion was observed in a dose-related fashion, regardless of timing and type, although some heterogeneity was detected. Data on surgical techniques were not available for further analysis. CONCLUSIONS: A consistently detrimental association was discovered between the use of perioperative blood transfusion and colorectal cancer recurrence. Further studies are needed to confirm that blood transfusion has a causal association.Presented in part at the meeting of UCP Club, the Association of the Coloproctology Units of Italy, Milan, Italy, November 11 to 12, 1995.     

DNA index as a significant predictor of recurrence in colorectal cancer

PURPOSE: To clarify the prognostic significance of the DNA content in cases of colorectal cancer, we investigated the relationship between the DNA content, as determined by the DNA ploidy or DNA index, and disease-free survival. RESULTS: This study included 201 cases that were treated by curative surgery between 1989 and 1995 at our hospital. 68 were diploid and 133 were aneuploid. The mean DNA index of these tumors was 1.42. Recurrence occurred in 30 cases (14.9 percent). Tumor site, venous invasion, Dukes stage, DNA ploidy (diploid or aneuploid), and a DNA index (less than or greater than 1.4) correlated well with disease-free survival. A multivariable analysis suggested the DNA index to be a stronger predictor than DNA ploidy. Patients with aneuploid tumors had shorter disease-free survival than those with diploid tumors (P=0.011), especially in Dukes Stage C cases (P=0.0209). Patients with a DNA index greater than 1.4 also had a shorter disease-free survival than those with a DNA index less than 1.4 (P<0.001), especially in Dukes Stage C cases (P=0.0033). CONCLUSIONS: The DNA index value (less than or greater than 1.4) seems to be a stronger predictor than DNA ploidy (diploid or aneuploid), and the combination of Dukes stage, tumor site, and a DNA index is, therefore, considered to be clinically valuable in predicting recurrence in cases of colorectal cancer.Presented at the meeting of the Japanese Society of Gastroenterological Surgery, Yokohama, Japan, July 17 to 18, 1997.     

Perioperative blood transfusion increases the risk of recurrence in colorectal cancer

A retrospective study was conducted on 519 patients undergoing curative resection for colorectal carcinoma between 1969 and 1980. Recurrence was diagnosed in 214 patients (41.2 percent), 179 of whom (34.5 percent) had received blood transfusions and 35 of whom (6.7 percent) had not (P<.001). Exclusion of the right-sided colonic tumors still showed that recurrence was more common in transfused than nontransfused patients (135 [47.2 percent] vs. 25 [22.5 percent];P<.001). Recurrence in patients transfused only during surgery (N=201) was higher than in nontransfused patients (P<.001) and, similarly, all patients transfused during surgery (N=297) had an increased risk (P<.001). Among patients with rectal cancer, transfusion increased the risk of recurrence in those treated by abdominoperineal resection (P<.02), but this was not the case in those treated by sphincter-saving resection (P=.2). Hierarchical log linear analysis of all dependent factors (Dukes' stage, histologic grade, age, sex, site, elective, or emergency procedure) showed that Dukes' stage and blood transfusion had the most significant effects on the development of recurrence (χ²=54.04, df=6,P<.0001 and χ²=13.93, df=3,P<.003). The risk of recurrence following curative surgery for colorectal cancer is markedly increased by blood transfusion on the day of operation. Poster presentation at the meeting of the American Society of Colon and Rectal Surgeons, Anaheim, California, June 12 to 17, 1988.     

Role of serum carcinoembryonic antigen in the detection of colorectal cancer before and after surgical resection

AIM: To determine whether serum levels of carcinoembryonic antigen (CEA) correlate with the presence of primary colorectal cancer (CRC), and/or recurrent CRC following radical resection.METHODS: A total of 413 patients with CRC underwent radical surgery between January 1998 and December 2002 in our department and were enrolled in this study. The median follow-up period was 69 mo (range, 3-118 mo), and CRC recurrence was experienced by 90/413 (21.8%) patients. Serum levels of CEA were assayed preoperatively, and using a cutoff value of 5 ng/mL, patients were divided into two groups, those with normal serum CEA levels (e.g., ≤ 5 ng/mL) and those with elevated CEA levels (> 5 ng/mL).RESULTS: The overall sensitivity of CEA for the detection of primary CRC was 37.0%. The sensitivity of CEA according to stage, was 21.4%, 38.9%, and 41.7% for stages I-III, respectively. Moreover, for stage II and stage III cases, the 5-year disease-free survival rates were reduced for patients with elevated preoperative serum CEA levels (P < 0.05). The overall sensitivity of CEA for detecting recurrent CRC was 54.4%, and sensitivity rates of 36.6%, 66.7%, and 75.0% were associated with cases of local recurrence, single metastasis, and multiple metastases, respectively. In patients with normal serum levels of CEA preoperatively, the sensitivity of CEA for detecting recurrence was reduced compared with patients having a history of elevated CEA prior to radical resection (32.6% vs 77.3%, respectively, P < 0.05).CONCLUSION: CRC patients with normal serum CEA levels prior to resection maintained these levels during CRC recurrence, especially in cases of local recurrence vs cases of metastasis.     

Fecal calprotectin concentration in patients with colorectal carcinoma

PURPOSE: The study contained herein was undertaken to investigate fecal calprotectin excretion in a series of patients with colorectal carcinoma and to determine whether the excretion was influenced by localization or stage of the tumor. Furthermore, the effect of surgical treatment on the concentrations was studied. Fecal calprotectin was also compared with plasma concentrations of calprotectin, carcinoembryonic antigen, and C-reactive protein. METHODS: Fecal calprotectin was measured in 119 consecutive patients admitted for treatment of colorectal carcinoma. In 116 (97.5 percent) patients, resectional surgery was performed. Plasma calprotectin was measured in 90 (76 percent) patients, carcinoembryonic antigen in 88 (74 percent) patients, and C-reactive protein in 82 (69 percent) patients. RESULTS: Median fecal calprotectin concentration in the 119 patients was 50 (range, 2-950) mg/l, which was significantly (P<0.0001) higher than in 125 control patients (median, 5.2 mg/l). In 23 patients studied also after resection, the excretion fell greatly. There were no significant differences in fecal calprotectin concentration among patients with different tumor stages. Elevated plasma calprotectin concentrations were found in 67 of 90 (73.3 percent) patients with colorectal carcinoma, compared with elevated fecal calprotectin in 111 of 119 (93.3 percent) patients, and there was no significant correlation between plasma and fecal calprotectin concentrations. Plasma calprotectin concentrations were significantly lower in patients with T1 or T2 tumors than in those with more advanced stages (P=0.0025). CONCLUSION: Measurement of fecal calprotectin may become a diagnostic tool in detecting colorectal carcinoma. The specificity in relation to colorectal carcinoma has not, however, been completely investigated. Both neoplastic and inflammatory conditions may be associated with elevated values; therefore, it is unlikely that calprotectin can predict specific colonic disorders.     

Surgical dilemmas in the management of colorectal liver metastases: the role of timing

Colorectal cancer (CRC) is an emerging health problem in the Western World both for its raising tendency as well as for its metastatic potential. Almost half of the patients with CRC will develop liver metastases during the course of their disease. The liver surgeon dealing with colorectal liver metastases faces several surgical dilemmas especially in the setting of the timing of operation. Synchronous resectable metastases should be treated prior or after induction chemotherapy? Furthermore in the case of synchronous colorectal liver metastases which organ should we first deal with, the liver or the colon? All these questions are set in the editorial and impulse for further investigation is put focusing on multidisciplinary approach and individualization of treatment modalities.     

Surgical management of gallbladder sarcomatoid carcinoma

AIM： To study the behavior as well as optimal treatment of gallbladder sarcomatoid carcinoma, we reviewed the results of treatment of gallbladder sarcomatoid carcinoma from Chang Gung Memorial Hospital. METHODS： From 1987 to 2005, six patients were diagnosed with gallbladder sarcomatoid carcinoma and treated at our institution. Tumor staging was based on 2002 revised tumor-node-metastasis （TNM） staging for gall bladder cancer from the American Joint Committee on Cancer. The clinical presentation, laboratory data and preoperative workup were reviewed retrospectively. RESULTS： Five patients were female and one was male. The age ranged from 51 to 66 years （median, 58 years）. Surgical procedures included three curative resections, two palliative resections and one biopsy. There were two surgical complications （33.3%） and one case of surgical mortality （16.7%）. The follow- up time ranged from 30 d to 5 mo. The median survival was 2.5 mo. The prognosis was extremely poor, even after curative resection and postoperative chemotherapy. CONCLUSION： The prognosis of gallbladder sarcomatoid carcinoma was not dependent on TNM stage and was always dismal. The clinicopathological features were different from those of gall bladder cancer.     

Role of colonic stents in the management of colorectal cancers

Colorectal cancer is one of the commonly encountered cancers across the Western World. In United Kingdom, this constitutes third most common ranked cancer and second most common ranked cause of cancer related deaths. Its acute presentation as a malignant colonic obstruction imposes challenges in its management. Colonic stent has been used for many years to alleviate acute obstruction in such cases allowing optimisation of patient’s physiological status and adequate staging of cancer. In this review, current literature evidence regarding use of colonic stent in acute malignant colonic obstruction is critically appraised and recommendations on the use of colonic stent are advocated.     

Pulmonary metastasectomy in colorectal carcinoma

Colorectal cancer (CRC) is one of the leading causes of cancer-related deaths worldwide. It is estimated that 50% of all patients with CRC develop metastases, most commonly in the liver and the lung. Lung metastases are seen in approximately 10–15% of all patients with CRC. A large number of these patients with metastatic CRC can only receive palliative treatment due to invasion of other organs and disseminated disease. However, a subset of these patients present with potentially resectable metastases. Pulmonary metastasectomy is considered to be a potentially curative treatment for selected patients with resectable metastatic CRC. Current data suggest that patients that undergo pulmonary metastasectomy have 5-year survival rates of approximately 40%. However, the majority of data published regarding lung metastasectomy is based on small, retrospective case series. Due to this lack of prospective data, it is still unclear which subset of patients will benefit most from curative-intent surgery. Furthermore, there is also controversy regarding which prognostic and genetic factors are related to survival outcomes and whether there is a difference between open and thoracoscopic approaches in terms of overall and disease-free survival. In this review, we aim to summarize the latest data on prognostic factors and survival outcomes after pulmonary metastasectomy in patients with metastatic CRC.     

Liver resection or cryotherapy for colorectal liver metastases

Background and aims While there is promising survival data for cryosurgery of colorectal liver metastases, local recurrence following cryoablation remains a problem. We aimed to compare morbidity and mortality, as well as the recurrence pattern and survival after liver resection and cryotherapy (alone or in combination with resection) for liver metastases.Patients and methods Between 1996 and 2002, 168 patients underwent liver resection alone and 55 patients had cryotherapy (25 in combination with liver resection) for colorectal liver metastases. The patient, tumour and operative details were recorded prospectively and the two patient groups were compared regarding morbidity, survival and recurrence.Results More patients had a prior liver resection, liver metastases were smaller and less frequently synchronous, morbidity was significantly lower and hepatic recurrence was significantly more frequent in the cryotherapy group. Five-year survival rates following resection and cryotherapy were comparable (23 and 26% respectively), while overall and hepatic recurrence-free survival was inferior following cryotherapy.Conclusion Cryotherapy is a valuable treatment option for some patients with non-resectable colorectal liver metastases. While survival is comparable to that after resection, higher hepatic recurrence rates following cryotherapy should caution against the use of cryotherapy for resectable disease until the results of randomized controlled trials are available.     

Endoscopic follow-up after colorectal cancer resection: An Italian multicentre study

BACKGROUND: Endoscopic follow-up is advised in patients operated for colorectal cancer due to a high risk for both metachronous colorectal cancer and adenomas. Such issue has been scarcely addressed in Italy. This study aimed to evaluate the incidence of neoplastic lesions at a scheduled endoscopic follow-up and to identify the patients at higher risk of recurrence. METHODS: Colorectal cancer patients diagnosed in the three participating hospitals (one North, one Centre and one South Italy) were scheduled for colonoscopies at 1, 3 and 5 years after surgery. Incidence of adenomas, advanced adenomas and colorectal cancer was assessed in all patients. Neoplastic incidence in patients with and without synchronous lesions at entry was also compared. RESULTS: Overall, 318 consecutive patients were prospectively enrolled including 108 (34%, group A) with a synchronous lesion and 210 (group B) without it. A cumulative neoplastic incidence of 20.1, 32.4 and 44% was observed at 1, 3 and 5 years of follow-up, respectively. The cumulative incidence of all the lesions was 70% in group A and 30.2% in group B at 5-year follow-up, being 39.5 and 15.5% after excluding the lesions detected at 1-year examination. A neoplastic lesion was detected more frequently in group A at 1year (30.5% versus 14.7%; p = 0.0013), 3 years (21.4% versus 7.6%; p = 0.0008) and at 5years (18.1% versus 7.8%; p = 0.02). CONCLUSIONS: Our data showed that the incidence of adenomas in patients operated for colorectal cancer is fairly high. Colorectal cancer patients with synchronous lesions are at higher risk of neoplastic recurrence at follow-up as compared to those without them.     

palliative care and end-stage colorectal cancer management:The surgeon meets the oncologist

Colorectal cancer(CRC)is a common neoplasia in the Western countries,with considerable morbidity and mortality.Every fifth patient with CRC presents with metastatic disease,which is not curable with radical intent in roughly 80%of cases.Traditionally approached surgically,by resection of the primitive tumor or stoma,the management to incurable stageⅣCRC patients has significantly changed over the last three decades and is nowadays multidisciplinary,with a pivotal role played by chemotherapy(CHT).This latter have allowed for a dramatic increase in survival,whereas the role of colonic and liver surgery is nowadays matter of debate.Although any generalization is difficult,two main situations are considered,asymptomatic(or minimally symptomatic)and severely symptomatic patients needing aggressive management,including emergency cases.In asymptomatic patients,new CHT regimens allow today long survival in selected patients,also exceeding two years.The role of colonic resection in this group has been challenged in recent years,as it is not clear whether the resection of primary CRC may imply a further increase in survival,thus justifying surgeryrelated morbidity/mortality in such a class of shortliving patients.Secondary surgery of liver metastasis is gaining acceptance since,under new generation CHT regimens,an increasing amount of patients with distant metastasis initially considered non resectable become resectable,with a significant increase in long term survival.The management of CRC emergency patients still represents a major issue in Western countries,and is associated to high morbidity/mortality.Obstruction is traditionally approached surgically by colonic resection,stoma or internal by-pass,although nowadays CRC stenting is a feasible option.Nevertheless,CRC stent has peculiar contraindications and complications,and its long-term cost-effectiveness is questionable,especially in the light of recently increased survival.Perforation is associated with the highest mortality and remains mostly matter for surgeons,by abdominal lavage/drainage,colonic resection and/or stoma.Bleeding and other CRC-related symptoms(pain,tenesmus,etc.)may be managed by several mini-invasive approaches,including radiotherapy,laser therapy and other transanal procedures.     

Intensive or not surveillance of patients with colorectal cancer after curative resection

It is common practice to follow patients with colorectal cancer for some years after resection and/or adjuvant treatment.Data are lacking about how often patients should be seen,what tests should be performed,and what surveillance strategy has a signifi cant impact on patient outcome.Seven randomized trials have addressed this issue,but none had sufficient statistical power.Four published meta-analyses have established that overall survival is significantly improved for patients in the more intensive progra...