Examination of nodal metastases by a clearing method supports pelvic plexus preservation in rectal cancer surgery

PURPOSE: In rectal cancer surgery preservation of urinary and sexual function is attempted by means of operations preserving the autonomic nerves of the pelvic plexus. Emergence of residual cancer because of a more shallow plane of dissection is a problem of concern with these methods, so we examined indications for pelvic plexus preservation. METHODS: We studied 198 patients with rectal carcinoma who underwent abdominopelvic lymphadenectomy. Lymph nodes along the superior hemorrhoidal artery and middle hemorrhoidal artery medial to the pelvic plexus were defined as perirectal nodes, and nodes along the middle hemorrhoidal artery lateral to the pelvic plexus and along the internal iliac artery represented lateral intermediate nodes. Node metastases were examined by the clearing method. RESULTS: Metastasis to perirectal nodes occurred in 12.5 percent in patients with pT1 tumors, 28.9 percent of those with pT2 tumors, and 50.0 percent of those with rectosigmoid junctional cancer. Metastasis to lateral intermediate nodes was absent in patients with pT1 or pT2 tumors and was as low as 2.5 percent in patients with rectosigmoid junctional cancer. CONCLUSIONS: In patients with T1, T2, and rectosigmoid junctional cancer, perirectal node dissection is necessary, but chances of residual cancer should remain minimal when the pelvic plexus is preserved.     

Can pathological complete response in the primary tumour following pre-operative pelvic chemoradiotherapy for T3–T4 rectal cancer predict for sterilisation of pelvic lymph nodes, a low risk of local recurrence and the appropriateness of local excision?

Introduction Local excision is considered inappropriate treatment for T3–T4 rectal adenocarcinomas, as it cannot provide prognostic information regarding lymph node involvement and has a high risk of pelvic recurrence. Preoperative chemoradiation (CRT) studies in rectal cancer suggest that a pathological complete response (pCR) in the primary tumour provides an excellent long-term outcome. If downstaging to stage pT0 predicts a tumour response within the perirectal and pelvic lymph nodes, this may allow local excision to be performed without increased risk of pelvic recurrence. This retrospective study aimed to determine the incidence of involved lymph nodes following pCR (ypT0) after preoperative CRT and total mesorectal excision.Method The outcome and treatment details of 211 patients undergoing preoperative CRT for clinically staged T3–T4 unresectable rectal adenocarcinomas between 1993 and 2003 at Mount Vernon Hospital were reviewed.Results Data were recorded from the 143 patients who completed treatment with a median follow-up of 25 months. Twenty-three patients (18%) were found to have had a pCR. Four out of 23 patients (17%) had involved lymph nodes. No pelvic recurrences developed after a ypCR. Overall survival was similar for patients with ypT0 or residual tumour.Conclusion Pathological complete response in the primary tumour failed to predict a response in the perirectal lymph nodes (p=0.08). The degree of response predicted a lymph node response (p=0.02). The detection of ypCR identified patients with a low rate of pelvic recurrence. This may in the future allow selection of patients for whom local excision can be performed without a higher risk of local relapse.On behalf of the Mount Vernon Colorectal Cancer Network     

Mesorectal Lymph Nodes: Their Location and Distribution Within the Mesorectum

PURPOSE: Total mesorectal excision is an alternative surgical approach for resectable rectal cancer and is associated with favorable results and a low rate of local recurrence. Despite the popularity of this technique, few data exist regarding the location and distribution of lymph nodes within the rectal mesentery. The purpose of this study was to define the distribution, size, and location of lymph nodes within the mesorectum and on the pelvic side wall. METHODS: Seven fresh cadavers at our institution's Fresh Tissue Dissection Laboratory were studied. The rectum, its mesentery, and all fatty tissue from both pelvic side walls were removed and placed in a lymph node clearing solution for 24 hours. After appropriate dissection, the distribution, size, and location of lymph nodes within the rectal mesentery and pelvic side wall tissue were documented. RESULTS: A total of 174 lymph nodes were identified (approximately 25 per patient). The majority (>80 percent) of lymph nodes were smaller than 3 mm in diameter. Fifty-six percent of the nodes within the rectal mesentery were located in the posterior mesentery, and most were located in the upper two-thirds of the posterior rectal mesentery. CONCLUSIONS: The majority of perirectal lymph nodes are small. There are few lymph nodes within the mesentery of the lower third of the rectum and relatively few in the right and left lateral portions of the mesorectum. We confirm that the majority of nodes are located in the proximal two-thirds of the posterior rectal mesentery. It is possible that removal of these nodes is responsible for the superior oncologic results found with total mesorectal excision in contrast to more traditional surgical techniques.     

Total Mesorectal Excision Results in Low Local Recurrence Rates in Lymph Node-Positive Rectal Cancer

PURPOSE: Most series report lymph node involvement as the main predictor for local recurrence. The principal lymphatic drainage of the rectum is to nodes in the mesorectum and then nodes along the superior rectal and inferior mesenteric arteries. If total mesorectal excision provides adequate block dissection of the lymphatics of the rectum, good local control with low rates of local recurrence should be achieved even in node-positive disease.METHODS: Prospective data on all rectal cancers have been collected since 1978; 170 patients with Dukes C rectal cancer have undergone anterior resection and total mesorectal excision. We did not perform any internal iliac node dissections. Follow-up data were analyzed for local recurrence and distant recurrence.RESULTS: The local recurrence rate was 2 percent for Dukes A cases, 4 percent for Dukes B, and 7.5 percent for Dukes C (P = 0.0127). The systemic recurrence rate was 8 percent for Dukes A, 18 percent for Dukes B, and 37 percent for Dukes C (P = 0.0001).CONCLUSIONS: If surgical priority is given to the difficult task of excision of the whole mesorectum, anterior resection with total mesorectal excision in node-positive rectal cancer, local recurrence rates of < 10 percent can be achieved.Presented at the Association of Colorectal Surgeons of Great Britain and Ireland, Harrogate, United Kingdom, June 25 to 27, 2001.     

Isolated tumor cell in lateral lymph node has no influences on the prognosis of rectal cancer patients

BACKGROUND AND AIMS: The aim of this study was to determine the incidence of isolated tumor cells (ITC) and micrometastasis in lateral lymph nodes of patients with rectal cancer and its possible correlation with prognosis. MATERIALS AND METHODS: One hundred seventy-seven rectal cancer patients who underwent curative resection with lateral lymph node dissection were enrolled. Dissected lymph nodes were examined using hematoxylin-eosin staining (HE) and immunohistochemistry (IHC) with anti-keratin antibody (AE1/AE3). States of lymph node metastasis were divisible into three groups: detectable with HE (HE+), detectable with only IHC (HE-/IHC+), and undetectable even with IHC (IHC-). Almost all the HE-/IHC+ group was classified as ITC consisting of a few tumor cells according to the UICC criteria (ITC+). Survival rates were compared among HE+, ITC+, and IHC-. RESULTS: ITC+ were detected in 24.1% of patients with HE-negative lateral lymph nodes. No significant difference in overall 5-year survival was observed between ITC+ and IHC- patients (76.1 and 82.9%, respectively, p = 0.25). Multivariate analysis showed that perirectal HE+ lymph nodes, but not ITC+ lateral lymph nodes, was an independent prognostic factor. CONCLUSIONS: ITC in lateral lymph nodes does not contribute to the prognosis of rectal cancer in patients who undergo extended lateral lymph node dissection, unlike HE+ lateral lymph node metastasis.     

Prognostic Significance of Lateral Lymph Node Micrometastases in Lower Rectal Cancer

PURPOSE: The aims of this study were to determine the rate of lymph node micrometastases and to evaluate their prognostic value in lateral lymph nodes in lower rectal cancer at or below the peritoneal reflection. METHODS: A retrospective analysis was made of 892 lymph nodes from 66 consecutive patients who had undergone radical resection with lateral lymph node dissection. These lymph nodes were examined immunohistochemically with an antibody against cytokeratins 7 and 8, CAM5.2. RESULTS: Routine hematoxylin-eosin staining revealed 9 patients with positive lateral lymph nodes that were stained consistently with CAM5.2. Among 57 patients in whom lateral lymph node metastases were not detected by hematoxylin-eosin staining, cytokeratin staining was positive in 19 nodes (2.7 percent) from 11 patients (19.3 percent). These 11 patients with micrometastases in lateral nodes showed a significantly high recurrence rate (P = 0.048) and worse overall survival (P = 0.01) than the 46 patients without lateral node metastases. The recurrence rate and overall survival of patients with micrometastases did not differ significantly from those of patients with positive lateral nodes with hematoxylin-eosin staining. Local recurrence developed in 6 of 66 patients, but neither the presence nor the absence of micrometastases in lateral nodes influenced the local recurrence rate. CONCLUSION: The presence of nodal micrometastases leads to a poor prognosis. The survival of patients with micrometastases was not different from that of patients with overt metastases. Therefore, patients with cytokeratin-positive cells in lateral lymph nodes should be regarded as having overt metastases.     

Prognostic significance of extranodal microscopic foci discontinuous with primary lesion in rectal cancer

PURPOSE: The most common recurrence after curative resection of rectal carcinoma originates from tiny, undetectable residual foci within the pelvic cavity. The significance and methods used to predict the presence of extramural and extranodal microscopic cancer foci discontinuous with the main lesion of rectal cancers were investigated. METHODS: Four hundred twenty-seven patients who underwent resection of rectal carcinoma were studied. All resected specimens were examined for histologic evidence of extramural cancer separate from the main lesion. RESULTS: Extramural cancers not in continuity with the main rectal lesion were classified as follows: 1) extranodal microscopic cancers; 2) large tumor nodules; 3) lymph node metastases. Each classification was found to influence long-term prognosis. Among them, microscopic cancer was thought to be especially relevant because, by virtue of its microscopic nature, it may be left in the pelvic cavity, causing local recurrence. The existence of large tumor nodules and metastatic lymph nodes correlated closely with the presence of microscopic cancer. Because large tumor nodules and lymph node metastases are possibly detectable during the operation by palpation and may be analyzed by microscopic frozen sections, they might be useful predictors of the presence of microscopic cancers. CONCLUSIONS: In cases with extensive local rectal cancer spread, the nerve-sparing rectal resection that omits lateral dissection may be insufficient for local control because of incomplete removal of occult microscopic cancer, resulting in local recurrence. Presence of microscopic cancer correlates closely with large tumor nodules and metastatic lymph nodes. Intraoperative frozen section investigations may, thus, help in deciding on extent of location resection.     

Postoperative Radiotherapy for Stage IIIA Rectal Cancer: Is It Justified?

Purpose  Adjuvant radiotherapy is currently recommended for all node-positive rectal cancers to reduce local recurrence. This study evaluated if an adequate mesorectal excision can obviate the need for radiotherapy in early node-positive cancer. Methods  Stage IIIA rectal cancer patients were identified in a prospectively maintained database. Patients who received postoperative radiotherapy (radiotherapy) and those who did not (no radiotherapy) were compared for recurrence, survival, bowel function, and quality of life. Quality of life was assessed using the Short Form-36 Medical Outcomes Survey. Results  Eighty-six patients underwent proctectomy for T1-T2,N1 rectal cancers from 1978 to 2004. Patients receiving radiotherapy (n = 34) were younger and had a higher percentage of T1 tumors than patients who did not receive radiotherapy (n = 52). Other tumor characteristics, type of surgery, and number of involved lymph nodes were comparable. Estimated 5-year local recurrence was radiotherapy 3.4 percent and no radiotherapy 4.7 percent; distant recurrence was radiotherapy 13.5 percent and no radiotherapy 16.5 percent; and disease-specific mortality rates were similar 13.5 vs. 11.3 percent, for radiotherapy and no radiotherapy (all P > .05). Patients receiving radiotherapy had higher frequency of daytime bowel movements, urgency, and usage of pads and antidiarrheal medications. Age adjusted quality of life parameters were comparable between treatments. Conclusion  Postoperative radiotherapy did not reduce recurrence or mortality. Function but not quality of life was adversely affected. Routine postoperative radiotherapy for Stage IIIA rectal cancer should be reconsidered. Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 6, 2007.     

Advances in rectal cancer surgery in Japan

A review of advancement of rectal cancer surgery in Japan is presented. The standard operation for rectal cancer was altered in the 1960s from abdominoperineal resection to the pull-through technique and the handsewn anterior resection in the 1970s, and it became the stapled anterior resection in the 1980s. Today, more than 75 percent of rectal cancers are treated with sphincter-preserving anterior resections, and the remaining 20 percent by abdominoperineal resections. Colonic J-pouch is used with anastomoses involving very low anterior rectal resection for cancers. In the late 1970s, a method of dissecting extended pelvic nodes was adopted to decrease local recurrence. However, extended dissection has been applied to only T3 and T4 cancers of the lower rectum because of postoperative dysfunction of pelvic organs. This was caused by injury to the pelvic nerve plexus, thus lowering the quality of life of the patients. Since the middle of the 1980s, the autonomic nerve-preserving operation attracted surgeons' attention because it prevented these dysfunctions from occurring as a result of the treatment of cancer in the upper rectum and for T1 or T2 cancers in the lower rectum. In this article, recent advances in rectal cancer surgery in Japan are reviewed.     

Ultrasonographic examination for lateral lymphatic spread and local recurrence of rectal cancer

PURPOSE: A preoperative evaluation of the lateral lymphatic spread is essential to decide the indication of autonomic nerve preserving operation for rectal cancer. For this evaluation, we used common ultrasonographic examination of the lower abdomen. We also performed this examination on postoperative patients in whom local recurrence had been suspected. Results and effectiveness of examination were evaluated. METHOD: First, we identified arteries in the pelvic cavity (common, external, and internal iliac arteries), and then we sought lymph nodes in the spaces between these arteries, urinary bladder, and rectum. RESULTS: We performed this examination on 40 preoperative patients with rectal cancer and could detect lymph nodes in 12 patients. By the size and features of these lymph nodes, five patients were considered lateral lymphatic spreadpositive. After the operation, resected specimens revealed three patients were pathologically positive, and the two others were false-positive. Only one patient was false-negative. Total accuracy of the examination was 92.5 percent; however, the positive lymph node around middle rectal artery and obturator artery had been overlooked. We also performed this examination on postoperative patients in whom local recurrence had been suspected. In one postoperative patient, a recurrent lesion of 30 × 3.5 cm in size was detected along the right external iliac artery and could be resected by the retroperitoneal surgical approach. CONCLUSION: We consider this examination very effective for detecting lymph node metastasis preoperatively and recurrent lesions in the pelvic cavity.     

Comparative Analysis of Nodal Upstaging Between Colon and Rectal Cancers by Sentinel Lymph Node Mapping: A Prospective Trial

PURPOSE Sentinel lymph node mapping accurately predicts nodal status in >90 percent of melanoma and breast and colorectal cancers. However, because of anatomic differences, sentinel lymph node mapping of rectal cancers has been considered inaccurate and difficult relative to colon. A prospective study was undertaken to identify differences in sentinel lymph node mapping between patients with colon cancer and those with rectal cancer.METHODS At operation 1 to 3 ml of 1 percent isosulfan blue dye was injected subserosally around colon cancers. The first to fourth blue-staining nodes seen within ten minutes of injection were marked as sentinel lymph nodes. For cancer of the mid-rectum to low rectum, the dye was injected submucosally via rigid scope and spinal needle. The mesorectum was dissected ex vivo to identify blue nodes nearest the tumor as sentinel lymph nodes. Multilevel microsections of sentinel lymph nodes were stained with hematoxylin and eosin and immunostained for cytokeratin, and standard examination of the entire specimen was performed.RESULTS There were 407 consecutive patients (336 with colon and 71 rectum). The sentinel lymph nodes were identified in 99.1 percent of colon and 91.5 percent of rectal patients (P < 0.0001). Skip metastases were found in 3.6 percent of colon vs. 2.8 percent of rectal patients (P = 0.16). Occult micrometastases were found in 13.4 percent of colon vs. 7.0 percent of rectal patients (P = 0.24). Except for success rates, no other parameters were statistically different between colon and rectum. Lower success in sentinel lymph node identification in rectal cancer may have been related to neoadjuvant chemoradiation received in all six of the patients with sentinel lymph node mapping failures.CONCLUSION Despite higher success rates in sentinel lymph node identification for colon patients, sentinel lymph node mapping was highly successful (91.5 percent) in rectal patients. Nodal upstaging, skip metastases, and occult metastases were similar.Read at the meeting of the American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, June 21 to 26, 2003.     

直肠癌侧方淋巴结清扫的再思考

直肠淋巴流向的研究从1895年D. Gerota的研究开始,提出了直肠淋巴流向可以分为上、中、下三个方向,经过很多学者的进一步研究修正,现普遍认为侧方淋巴流向可以分为4个方向：1.前方,由膀胱下动脉,前列腺动脉,经闭孔动脉到髂总动脉;2.沿直肠中动脉到髂内动脉;3.沿着骶中动脉和骶外侧动脉到腹主动脉分叉部位;4.沿着直肠下动脉到髂内动脉。侧方淋巴结转移主要发生在低位直肠癌,浸润深度大于肌层者,而转移的侧方淋巴结并不包括在直肠癌全直肠系膜切除术（TME）范围之内。NCCN直肠癌诊疗指南中没有提及侧方淋巴结的概念,日本大肠癌规约则认为有适应证的低位直肠癌应行侧方淋巴结清扫术。西方学者认为直肠癌侧方淋巴结转移是全身疾病,侧方淋巴结清扫难以改善总体临床结局;日本学者则认为是局部疾病,对低位直肠癌规范手术为TME＋侧方淋巴结清扫。西方学者认为术前放化疗可替代侧方淋巴结清扫;东方学者则认为对于术前放化疗不敏感的直肠癌患者,侧方淋巴结清扫术仍不失为一个可供选择的治疗方案。低位直肠癌患者是否应行预防性盆腔侧方淋巴结清扫仍存在争议,但治疗性侧方淋巴结清扫术则是日本的直肠癌规范治疗。不少研究报道了腹腔镜侧方淋巴结清扫术的初步探索结果,认为其是安全有效的,但其与开放手术的远期肿瘤学结果对比仍需多中心随机对照研究验证。     

Clinicopathological characteristics and prognosis of rectal well-differentiated neuroendocrine tumors

Background  To clarify the oncological outcome of rectal well-differentiated neuroendocrine tumors (W/D NETs), we examined the clinicopathological characteristics and prognosis of patients with this neoplasm. Materials and methods  A total of 23 patients who underwent surgical treatment with lymph node dissection for rectal W/D NETs between 1973 and 2007 were reviewed. Results  Median tumor size measured preoperatively was 13 mm (range, 4–25 mm), and the median number of dissected lymph nodes was 16 (range, 1–46). The incidence of lymph node metastasis was 61% (14 of 23 cases). The smallest W/D NETs with lymph node metastasis was 10 mm in diameter. All the patients without lymph node metastasis survived without recurrence. Among 11 patients who had only regional lymph node metastasis, only one developed liver metastasis and died 13 months after initial surgery. Among three patients with lateral pelvic lymph node metastasis, two survived more than 5 years, although two had liver metastasis. Conclusions  Because the incidence of lymph node metastasis is very high in patients with rectal W/D NETs greater than 10 mm in diameter, radical surgery is required. In this series, the outcome of rectal W/D NETs patients with lateral pelvic lymph node metastasis was better than expected.     

Surgical Salvage of Recurrent Rectal Cancer After Transanal Excision

PURPOSE This study examines surgical salvage of locally recurrent rectal cancer following transanal excision of early tumors.METHODS Through retrospective review of a colorectal database we identified 50 patients who underwent attempted surgical salvage for local recurrence following initial transanal excision of T1 or T2 rectal cancer. Eight patients had resectable synchronous distant disease. Clinicopathologic variables were associated with extent of surgery required for salvage and outcome.RESULTS Salvage procedures included abdominoperineal resection (31), low anterior resection (11), total pelvic exenteration (4), and transanal excision (3). One patient had unresectable disease at exploration, requiring diverting ostomy. Of the 49 patients who underwent successful salvage, 27 (55 percent) required an extended pelvic dissection with en bloc resection of one or more of the following structures: pelvic sidewall and autonomic nerves (18); coccyx or portion of sacrum (6); prostate (5); seminal vesicle (5); bladder (4); portion of the vagina (3); ureter (2); ovary (1); and uterus (1). Complete pathologic resection (R0) was accomplished in 47 of 49 patients. Of the eight patients with distant and local recurrence, two underwent synchronous resection and six had delayed metastasectomy. With a median follow-up of 33 months, 29 patients had recurred or died of disease at the time of this analysis. Five-year disease-specific survival was 53 percent. Factors predictive of survival included evidence of any mucosal recurrence on endoscopy, low presalvage carcinoembryonic antigen, and absence of poor pathologic features (lymphovascular and perineural invasion). Patients who required an extended pelvic resection had a worse survival rate.CONCLUSION Pelvic recurrence following transanal excision of early rectal cancer is often locally advanced, requiring an extended pelvic dissection with en bloc resection of adjacent pelvic organs to achieve salvage. The long-term outcome in patients undergoing resection is less than expected, considering the early stage of their initial disease. When contemplating local excision for early rectal cancer, the risk of local recurrence, the extent and morbidity of surgery required for salvage, and the modest cure rate following salvage should be considered.Read at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004.Reprints are not available.     

Factors influencing local recurrence after abdominoperineal resection for cancer of the rectum

Pelvic and perineal recurrences of cancer after rectal amputation are frequent, often isolated, and thus directly responsible for a fatal outcome by local decompression accidents or infection. This study explores the patterns of recurrence after “curative” operation for rectal cancers. One hundred thirteen patients who underwent abdominoperineal resection are reviewed: there were 36 local recurrences,i.e., an incidence of 31.8 percent. About 70 percent of these recurrences occurred within two years after surgical treatment. Low level of tumor in the rectum, local spread into perirectal fat or serosa, lymph node involvement, and histologic grade of malignancy were the only factors that were statistically related to local recurrence. The strategy for careful follow-up of patients at risk is outlined and a plea is made for a controlled trial of postoperative radiotherapy.     

Prognostic value of lateral lymph node metastasis for advanced low rectal cancer

AIM： To evaluate the risk factors for lateral lymph node metastasis in patients with advanced low rectal cancer, in order to make the effective selection of patients who could benefit from lateral lymph node dissection, as well as the relationship of lateral lymph node metastasis with local recurrence and survival of patients with advanced low rectal cancer. METHODS： A total of 96 consecutive patients who underwent curative surgery with lateral pelvic lymphadenectomy for advanced lower rectal cancer were retrospectively analyzed. The relation of lateral lymph node metastasis with clinicopathologic characteristics, local recurrence and survival of patients was identified. RESULTS： Lateral lymph node metastasis was observed in 14.6% （14/96） of patients with advanced low rectal cancer. Lateral lymph node metastasis was detected in 10 （25.0%） of 40 patients with tumor diameter ≥ 5 cm and in 4 （7.1%） of 56 patients with tumor diameter 〈 5 cm. The difference between the significant （X^2 = 5.973, P = two groups was statistically 0.015）. Lateral lymph node metastasis was more frequent in patients with 4/4 diameter of tumor infiltration （7 of 10 cases, 70.0%）, compared with patients with 3/4, 2/4 and 1/4 diameter of tumor infiltration （3 of 25 cases, 12.0%; 3 of 45 cases, 6.7%; 1 of 16 cases, 6.3%） （X^2 = 27.944, P = 0.0001）. The lateral lymph node metastasis rate was 30.0% （9 of 30 cases）, 9.1% （4 of 44 cases） and 4.5% （1 of 22cases） for poorly, moderately and well-differentiated carcinoma, respectively. The difference between the three groups was statistically significant （X^2 = 8.569, P = 0.014）. Local recurrence was 18.8% （18 of 96 cases）, 64.3% （9 of 14 cases）, and 11.0% （9 of 82 cases） in patients with advanced low rectal cancer, in those with and without lateral lymph node metastasis, respectively. The difference between the two groups was statistically significant （X^2 = 22.308, P = 0.0001）. Kaplan-Meier survival analysis showed significant impr     

The significance of abdominal para‐aortic lymph node metastasis in patients with lower thoracic esophageal cancer

Para‐aortic lymph node (PALN) recurrence is often seen in patients with lower thoracic esophageal cancer treated by esophagectomy with extended lymph node dissection. However, the clinicopathological characteristics of patients with PALN metastasis and the significance of PALN dissection are unknown. A total of 283 patients with lower thoracic esophageal cancer underwent esophagectomy with lymphadenectomy at our hospital between April 1984 and March 2007. Among these 283 patients, 60 patients were enrolled in this retrospective study according to following criteria: (i) clinical T2 to T4 tumor, (ii) no clinical PALN metastasis, and (iii) received PALN dissection. PALN dissection was indicated by a tumor depth of at least T2 and no severe complications. The clinicopathological data, recurrence pattern, and overall survival were compared between patients with PALN and without PALN metastasis. The mean length of surgery was 587 min and the mean blood loss was 1383 mL. The morbidity was 33.3% and mortality was 5% in this series. Sixteen patients (26.7%) had PALN metastasis; these showed significantly more lymph node metastases (15.8 ± 13.2 vs. 3.0 ± 3.2, P < 0.0001) and significantly worse survival rates (53.3% vs. 79.9% at 1 year, 6.7% vs. 62.0% at 3 years, P < 0.0001) than patients without PALN metastasis. The incidence of lymph node recurrence (P < 0.0001) and hematogenous recurrence (P= 0.0487) was also higher in patients with PALN metastasis than in patients without PALN metastasis. Among the 16 patients with PALN metastasis, a univariate analysis revealed total number of metastatic nodes < 8 (P= 0.0325) to be a significant prognostic factor. A multivariate logistic regression analysis of the regional lymph nodes identified the invasion of the lower mediastinal nodes (hazard ratio = 6.120) and retroperitoneal nodes (hazard ratio = 15.167) to be significantly correlated with PALN metastasis. PALN metastasis is suggested to be related to the systemic spread of lymphatic metastasis even in lower thoracic esophageal cancer. PALN dissection for pathological PALN(+) patients should not be performed. It remains to be determined in future prospective studies whether patients without pathological PALN metastasis, but showing PALN micrometastasis, could achieve improved survival with PALN dissection.     

Prognostic significance of depth of gross or microscopic perirectal fat invasion in T3 N0 M0 rectal cancers following sharp mesorectal excision and no adjuvant therapy

BACKGROUND AND AIMS. Although the standard of care for T3 and/or N1-2 rectal cancers includes adjuvant chemoradiation, it is unclear whether T3 N0 patients with limited microscopic perirectal fat invasion warrant further therapy. Our aim was to determine the prognostic significance of gross perirectal fat invasion, or depth of microscopic perirectal fat invasion, in T3 N0 rectal cancers following sharp mesorectal excision and no adjuvant therapy. PATIENTS AND METHODS. Utilizing a prospective database, the medical records of 108 patients who underwent a potentially curative resection for T3 N0 rectal cancer between June 1986 and December 1994 were analyzed. All pathological specimens were re-reviewed by a single pathologist, and extent of perirectal fat invasion was measured in millimeters. Patients who received either preoperative or postoperative adjuvant therapy were excluded. RESULTS. Macroscopic perirectal fat invasion (T3 gross) was present in 49 cases, absent in 40 cases (T3 microscopic), and not reported in 19 cases. Rectal cancers were stratified by extent of measured perirectal fat invasion into 3 mm or less and more than 3 mm. Five-year overall and local recurrence rates for the entire group were 19% and 8%, respectively. The disease-free survival, disease-specific survival, and overall recurrence for rectal cancers with 3 mm or less invasion vs. more than 3 mm invasion, or T3 gross vs. T3 microscopic, were not statistically different. CONCLUSION. Our data suggest that the extent of gross, or microscopic perirectal fat invasion (defined as >3 or 相似文献   

Distal intramural spread in adenocarcinoma of the lower third of the rectum treated with total rectal resection and coloanal anastomosis

PURPOSE: This study was designed to evaluate the frequency of microscopic distal intramural spread in rectal adenocarcinoma and its correlation to other histopathologic prognostic factors. METHODS: We examined 55 patients with adenocarcinomas of the lower one-third of the rectum and measured the extent of distal intramural spread in the submucosa and/or muscular layer in comparison with Dukes Stage, diameter of tumor, distance of distal margin of resection from tumor, depth of infiltration into perirectal adipose tissue, nodal status, neoplastic infiltration of lymphatic vessels, blood vessels, and nervous branches. RESULTS: Distal intramural spread was found in 40 percent of patients, 77 percent of whom had advanced tumors with nodal metastases. Distal intramural spread appeared to be strictly related to tumor size (superior to 40 mm), infiltration of the perirectal adipose tissue, multiple positive lymph nodes, presence of neoplastic emboli in the intramural lymphatic vessels, and neoplastic invasion of the nervous branches. Local recurrence occurred in one Dukes Stage B patient with a positive distal margin of resection and in four patients with a negative distal margin of resection: three Dukes Stage C and one Dukes Stage B patients with neoplastic involvement of the circumferential margin of resection of the mesorectum. CONCLUSION: These preliminary data suggest that distal intramural spread may carry little importance in determining local recurrence of rectal adenocarcinoma.Supported by Associazione Italiana Ricerca sul Cancro.     

Local recurrence following surgical treatment of rectal cancer

Three hundred twenty patients with rectal cancer were studied to determine factors that correlate with development of pelvic recurrence. The mean age was 65 years; anterior resection was performed in 202 (63 percent) and abdominoperineal resection in 118 (37 percent). Fifty-two patients (16 percent) developed pelvic recurrence. The mean duration of follow-up to development of pelvic recurrence was 22 months. Depth of tumor invasion, presence of lymph node metastasis, and colloid features were found to correlate with pelvic recurrence. The recurrence rate in patients having anterior resections was the same as that of patients undergoing abdominoperineal resections. Patients having anterior resection with distal margins of 1 cm or less had an extremely high recurrence rate (36 percent). Pelvic recurrent did not continue to improve when the distal margins were extended over 2 cm. Microscopic lateral tumor extension, which is not removed during operation, appears to be the major determinant of local recurrence in rectal cancer.