Long-term efficacy of preoperative radiotherapy for locally advanced low rectal cancer

Background and aims The purpose of this study was to assess the long-term efficacy of preoperative radiotherapy for locally advanced low rectal cancer. Materials and methods Between April 1990 and June 2005, all patients who underwent surgery for low rectal cancer with a pretreatment diagnosis of T3 or resectable T4 without distant metastasis were enrolled. The total dose of radiation was 45 Gy. Patients with a partial or complete response were defined as radiotherapy responders (RT-R) and the others as radiotherapy non-responders (RT-NR). Patients who did not receive radiotherapy were termed the non-radiotherapy group (NRT). The endpoint of this study was overall survival and local and/or distant metastasis. Results There were 24 patients in RT-R, 26 in RT-NR, and 40 in NRT. Gastrointestinal complications were commonly observed in all groups. RT-R had a significantly higher incidence of genitourinary complications. Five-year overall survival rate was 79.6% in RT-R, 58.9% in RT-NR, and 58.8% in NRT. The difference was significant in favor of RT-R over the others (P = 0.015, 0.024, respectively). Five-year local recurrence-free survival rate was 100% in RT-R, 81.5% in RT-NR, and 74.9% in NRT. RT-R had significantly improved local control compared with the others (P = 0.034, 0.021, respectively). Five-year distant metastasis-free survival was not statistically different among all groups. Conclusions Survival benefit of preoperative radiotherapy was limited to responders. Considering the increased risk of adverse effects, identification of predictors of radiosensitivity is required in order to provide the most suitable treatment for individual patients.     

Long-term survival after post-hepatectomy liver failure for colorectal liver metastases

Background

While post-hepatectomy liver failure (PHLF) accurately predicts short-term mortality, its role in prognosticating long-term overall survival (OS) remains unclear.

局部晚期直肠癌新辅助化疗的机遇

结直肠癌是最常见的消化道恶性肿瘤之一。在我国,结直肠癌的发病率呈逐年上升趋势,且我国直肠癌占结直肠癌的比例仍然明显高于欧美国家。术前或术后的同步放化疗已被证实可显著降低直肠癌的局部复发率,是目前局部晚期直肠癌围手术期的标准治疗模式。近年来,直肠癌新辅助化疗的作用越来越受到重视,本文就目前局部晚期直肠癌新辅助治疗存在的问题和以新辅助化疗为主的新治疗理念的研究现状进行阐述。     

Long-term survival and recurrences after total nerve-sparing surgery for rectal cancer

BACKGROUND/AIMS: In advanced extraperitoneal rectal cancer Japanese surgeons perform the lateral pelvic nodal dissection with only partial pelvic autonomic nerves preservation; instead most Western surgeons prefer the total mesorectal excision (TME) with complete pelvic nerve sparing except for evident neoplastic nervous involvement. Long-term oncological results of the total nerve-sparing TME are reported. METHODOLOGY: From January 1992 to October 1998 71 [corrected] patients with extraperitoneal rectal carcinoma underwent TME with total nerve sparing except in two cases in which only a partial sparing was possible because of macroscopic neoplastic nervous infiltration: 54 anterior resections and 17 abdominoperineal resections were performed. Sixty-one curatively operated patients (9 stage I, 20 stage II, 29 stage III and 3 stage IV) were included. RESULTS: No postoperative death occurred. Postoperative radiochemotherapy was performed in 31 cases, radiotherapy in 9 cases and chemotherapy in 9 cases. The mean follow-up was 98.7 months. The 5-year overall and disease-free survival rates were 88.8% and 77.7%, 90% and 75.1%, 62.3% and 45% for stage I, II and III respectively. The 8-year actuarial overall and disease-free survival rates were 77.7% and 77.7%, 78.3% and 75.1%, 50.4% and 40% for stage I, II and III respectively. Local failures with or without distant metastases were 6 (9.8%). CONCLUSIONS: Total nerve-sparing surgery is not contraindicated unless grossly neoplastic involvement is present.     

局部进展期直肠癌新辅助治疗的策略：分而治之

尽管术前放疗显著降低了局部进展期直肠癌的复发风险,但这种治疗模式不仅未能显著改善患者的总生存,而且还带来严重的远期毒性,使患者生存质量受到严重影响。本文将介绍该领域近年来的研究进展及对临床实践的影响。     

Extended lymphadenectomy for locally advanced and recurrent rectal cancer

Purpose

The purpose of this study is to assess the value of extended (lateral) lymphadenectomy (EL) in the operative management of locally advanced and recurrent rectal cancer.

Methods

Patients that underwent exenterative surgery for locally advanced or recurrent rectal cancer between 2006 and 2009 were included in the study. A decision for EL was taken at the local multidisciplinary meeting based on the radiological findings. Perioperative and oncological outcomes were assessed and compared between the EL and non-EL group prospectively.

Results

Forty-one consecutive patients were included in the study (EL = 17). The median age was 57 (40–71) for EL and 66 (39–81) years for non-EL. Of patients, 27 (EL = 13) and 14 (EL = 4) underwent pelvic exenteration and abdominosacral resection, respectively. Twelve (EL = 7) patients were diagnosed with locally advanced primary rectal cancer. Thirty-one (EL = 12) patients received neoadjuvant radiotherapy. The median intraoperative time, blood loss and hospital stay were 9 h (3–13), 1.5 l (0.3–7) and 14 days (12–72), respectively, for the EL group, and 8 h (4–15), 1.6 l (0.25–17) and 14 days (10–86), respectively, for the non-EL (p ≥ 0.394). Morbidity was similar between the two groups (EL = 4, non-EL = 9; p = 0.344). Complete tumour resection (R0) was achieved in 30 (73.17%) patients, 12 (70.58%) in the EL group and 18 (75%) in the non-EL group (p = 0.649). There was no significant difference in 5-year survival (EL = 60.7%, non-EL = 75.2%; p = 0.447), local recurrence (EL = 53.6%, non-EL = 65.4%; p = 0.489) and disease-free survival (EL = 53.6%, non-EL = 51.4%; p = 0.814).

Conclusions

The present study demonstrated that EL does not provide a statistically significant advantage in survival or recurrence rates, for patients with locally advanced primary or recurrent rectal cancer.

     

Extensive surgery after high-dose preoperative chemoradiotherapy for locally advanced recurrent rectal cancer

PURPOSE: This was a pilot study of high-dose preoperative concurrent radiation and chemotherapy before extensive surgery in patients with locally advanced recurrent rectal cancer. Here we report on curative resectability, acute toxicities during chemoradiotherapy, surgical complications, local control, and three-year survival rates achieved with this aggressive multimodal regimen. METHODS: Between 1994 and 1997, 35 previously nonirradiated patients with pelvic recurrence of rectal cancer were entered in the study. All patients presented with tumor contiguous or adherent to adjacent pelvic organs and were not deemed amenable to primary curative surgery. A total radiation dose of 50.4 Gy with a small-volume boost of 5.4 to 9 Gy was delivered in conventional fractionation (single dose, 1.8 Gy). 5-Fluorouracil was scheduled as a continuous infusion of 1,000 mg/m²/day on Days 1 to 5 and 29 to 33. Six weeks after completion of chemoradiotherapy, patients were reassessed for resectability, and radical surgery was attempted whenever feasible. RESULTS: After preoperative chemoradiotherapy 28 of 35 patients (80 percent) underwent resection with curative intent. In 16 of 35 patients (57 percent) extended resection of adjacent organs was performed. Resections with negative margins were achieved in 17 patients (61 percent); 9 patients had microscopic, and 2 patients had gross residual disease. There was no postoperative mortality. Fourteen patients (44 percent) experienced postoperative complications. Toxicity from chemoradiotherapy occurred mainly as diarrhea (National Cancer Institute Common Toxicity Criteria Grade 3; 23 percent), dermatitis (Grade 3; 11 percent), and leucopenia (Grade 3; 11 percent). One patient died of tumortoxic multiple organ failure during chemoradiotherapy. With a median follow-up of 27 months, local re-recurrence after curative resection was observed in only three patients (18 percent); six patients developed distant metastases. Three-year actuarial survival rate was significantly improved after complete resection (82 percent) as compared with noncurative surgery (38 percent;P=0.03). CONCLUSION: A combination of high-dose preoperative chemoradiotherapy followed by extended surgery can achieve clear resection margins in more than 60 percent of patients with recurrent rectal tumor not amenable to primary surgery. An encouraging trend evolved for this multimodal treatment to improve long-term local control and survival rate.Presented at the meeting of the German Society for Radiation Oncology, Radiation Biology and Medical Physics (DEGRO), Nürnberg, Germany, November 7 to 10, 1998.     

Long-term survival after gastrectomy and metastasectomy for gastric cancer with synchronous bone metastasis

Bone metastasis is a rare event in patients with gastric cancer, but pathologic fracture, paralysis, pain and hematological disorders associated with the bone metastasis may influence the quality of life. We report herein the case of a 53-year-old man who presented with primary remnant gastric cancer with bone metastasis. The patient requested further investigations after detection of a metastatic lesion in the 2 nd lumbar vertebra during evaluation for back pain that had persisted for 3 mo. No other metastatic lesions were detected. He underwent total gastrectomy and palliative metastasectomy to aid in reduction of symptoms, and he received combination chemotherapy with tegafur(S-1) and cisplatin. The patient survived for about 60 mo after surgery. Currently, there is no treatment guideline for gastric cancer with bone metastasis, and we believe that gastrectomy plus metastasectomy may be an effective therapeutic option for improving qualityof life and survival in patients with resectable primary gastric cancer and bone metastasis.     

Pre-operative radiochemotherapy of locally advanced rectal cancer

AIM. To evaluate results of pre-operative radiochemotherapy followed by surgery for 15 patients with locally advanced un-resectable rectal cancer.METHODS: 15 patients with advanced non-resectable rectal cancer were treated with pre-operative irriadiation of 40-46Gy plus concomitant chemotherapy (5-FU+LV and 5‘-DFuR) (RCS group). For comparison, 27 similar patients,treated by preoperative radiotherapy (40-50Gy) plus surgery were served as control (RS group).RESULTS: No radiochemotherapy or radiotherapy was interrupted and then was delayed because of toxicities in both groups. The radical resectability rate was 73.3% in the RCS group and 37.0% (P=0.024) in RS group. Sphincter preservation rates were 26.6% and 3.7% respectively(P=0.028). Sphincter preservation rates of lower rectal cancer were 27.3% and 0.0% respectively (P=0.014). Responserates of RCS and RS groups were 46.7 % and 18.5 %(P=0.053). The tumor downstage rates were 8(53.3%)and 9 (33.3%) in these groups (P=0.206). The 3-year overall survival rates were 66.7% and 55.6% (P=0.485), and the disease free survival rates were 40.1% and 33.2%(P=0.663). The 3-year local recurrent rates were 26.7% and 48.1% (P=0.174). No obvious late effects were found in either groups.CONCLUSION: High resectability is possible following preoperative radiochemotherapy and can have more sphincters preserved. It is important to improve the quality of the patients‘ life even without increasing the survival or local control rates. Preoperative radiotherapy with concomitant full course chemotherapy (5-Fu+LV and 5‘-DFuR) is effective and safe.     

Short-term preoperative radiotherapy is a safe approach for treatment of locally advanced rectal cancer

Background and aims The Swedish Rectal Cancer Trial (SRCT) demonstrated that a short term regimen of high-dose preoperative radiotherapy (5×5 Gy) not only reduces the risk of local recurrence but also improves overall survival rate. An increase in postoperative mortality and morbidity has also been observed, however. We therefore evaluated early postoperative complications in patients treated with neoadjuvant radiotherapy for locally advanced rectal adenocarcinoma.Patients/methods Between 2000 and 2004, 85 patients with locally advanced rectal tumors were treated in our institution. Preoperative staging was based on CT scan and, in several cases, on endorectal ultrasonography. They were 55 men and 30 women, with a median age of 68 years. They were retrospectively divided into two groups: Group A, which included 40 patients undergoing preoperative radiotherapy (25 Gy in five fractions) followed by surgery within 1 week, and Group B, which included 45 patients with rectal cancer receiving surgery immediately after diagnosis. Both groups were homogeneous regarding age, gender and preoperative stage of the disease. The two groups were compared for both technical difficulties during operation and rate of postoperative complications.Results/findings No postoperative deaths were recorded in either group. Low anterior resection with total mesorectal excision was performed in all group A patients, whereas eight patients in group B underwent abdominoperineal resection (P<0.05). Diverting stoma was performed in seven patients of group A and it was closed 3–6 months later on every occasion. Postoperative morbidity was not statistically significant between the two groups (40 vs 39%). The rate of postoperative hemorrhage, pelvic or abdominal wound infection, acute urinary infection, and delayed ileus was similar. The percentage of major anastomotic leak was also equivalent (5 vs 6.6%).Interpretation/conclusion Short-term preoperative radiotherapy does not increase the rate of postoperative complications and is a safe therapeutic adjunct for the treatment of locally advanced rectal cancer.     

Multimodality approach for locally advanced esophageal cancer

Carcinoma of the esophagus is an aggressive and lethal malignancy with an increasing incidence worldwide. Incidence rates vary internationally, with the highest rates found in Southern and Eastern Africa and Eastern Asia, and the lowest in Western and Middle Africa and Central America. Patients with locally advanced disease face a poor prognosis, with 5-year survival rates ranging from 15%-34%. Recent clinical trials have evaluated different strategies for management of locoregional cancer; however, because of stage migration and changes in disease epidemiology, applying these trials to clinical practice has become a daunting task. We searched Medline and conference abstracts for randomized studies published in the last 3 decades. We restricted our search to articles published in English. Neoadjuvant chemoradiotherapy followed by surgical resection is an accepted standard of care in the United States. Esophagectomy remains an essential component of treatment and can lead to improved overall survival, especially when performed at high volume institutions. The role of adjuvant chemotherapy following curative resection is still unclear. External beam radiation therapy alone is considered palliative and is typically reserved for patients with a poor performance status.     

直肠癌同时性肝转移的外科治疗

目的探讨直肠癌同时性肝转移外科治疗手术时机及方法。方法对2006年8月至2008年8月在我中心32例直肠癌同时性肝转移患者的诊断和治疗的临床资料进行回顾性分析。结果术前B超、CT、MRI能够明确诊断直肠癌肝转移灶能否手术切除;术前新辅助化疗及靶向治疗可以进一步筛选直肠癌肝转移;治疗模式是以手术为主的综合性治疗。结论可切除的直肠癌肝转移首选手术治疗;采取合适的、个体化综合治疗手段能够提高无瘤生存率和累计生存率。     

Prolonged survival after resection of pancreatoblastoma and synchronous liver metastases in an adult.

Pancreatoblastoma is an uncommon pediatric neoplasm with distinct acinar and squamoid cell differentiation. Pancreatoblastoma is exceedingly rare in adults with only ten reported cases. Pancreatoblastoma in adults has a poor prognosis and no survival without recurrence exceeding 30 months has been reported. We report the first adult case of pancreatoblastoma revealed by gastric bleeding due to segmental hypertension. On computed tomography scan, the tumor appeared lobulated and extended from the splenic hilum to the portal vein. Two hypervascular centimetric hepatic metastases were observed in segments III and VII. The patient was operated and a distal pancreatectomy with splenectomy associated with two hepatic wedge resections was performed. The diagnosis of pancreatoblastoma was made on immunohistochemical examination. The patient received 6 cycles of adjuvant therapy. After three years of follow-up, the patient was well with no sign of recurrence on computed tomography scan. This case suggests that in the presence of pancreatic tumor of unknown origin, aggressive management including complete surgical resection and adjuvant chemotherapy should be attempted even in the presence of synchronous liver metastases.     

The impact of pathologic nodal status on survival following neoadjuvant chemoradiation for locally advanced rectal cancer

Purpose

For patients with locally advanced rectal cancer, the accuracy rates of preneoadjuvant therapy nodal staging and potential nodal downstaging make the prognostic significance of nodal status unclear. We therefore sought to review our experience in order to better understand the impact of clinical and pathologic nodal status upon patient outcomes.

Methods

174 patients were identified as having undergone neoadjuvant chemoradiation and resection for rectal cancer. For analytic purposes, patients were grouped into four nodal categories (uN^?0·?pN^?0, uN^?0·?pN^?+, uN?⁺?·?pN^?0, and uN?⁺?·?pN^?+). Univariate and multivariate analyses were performed.

Results

104 men and 70 women of median age 60 years (29–85 years) were followed for a median of 31 months (1–121 months). Nodal staging was available for 129 patients, with a median of 8 lymph nodes (range 0–39) evaluated. Disease recurred in 3 of 41 (7 %) uN?? ⁰ ·pN ^??0, 10 of 52 (20 %) uN ^???+·pN ^??0, 7 of 18 (41 %) uN ^??0·pN ^???+, and 6 of 17 (35 %) uN ^??+·pN ^??+ patients. Those patients having nodal downstaging (uN ^??+·pN ^??0) experienced superior overall survival (p?=?0.03). Only pathologic nodal status was a significant predictor of both disease-free and overall survival in multivariate modeling. Adjuvant chemotherapy did not impact disease-free or overall survival for patients with pN0.

Conclusions

Pathologic nodal status may represent a superior predictor of survival for patients with local advanced rectal cancers. Our findings may have potential implications for the application of adjuvant therapy.     

Laparoscopic abdominosacral composite resection for locally advanced primary rectal cancer

Background  

En bloc resection of a primary rectal cancer that involves the sacrum is the only curative option for such locally advanced tumours. There is significant morbidity associated with this surgical procedure. A laparoscopic component would potentially provide the patient with the short-term benefits of a minimally invasive approach to the abdominal phase of this challenging operation. The aim of this study was to assess our initial experience with a combined laparoscopic and transsacral approach.     

预测局部晚期直肠癌新辅助放化疗疗效潜在的生物标记物

新辅助放化疗联合手术的治疗模式已成为局部晚期直肠癌（locally advanced rectal cancer,LARC）的标准治疗方案,准确预测新辅助放化疗后直肠肿瘤消退,特别是病理性完全缓解具有十分重要的意义,有助于为患者制定个体化治疗方案。因此,我们对可用于预测局部晚期直肠癌患者新辅助放化疗疗效的评价指标进行了综述和分析,并展望直肠癌放化疗疗效预测的进一步研究。