Ovarian metastases from colorectal cancer: a clinicopathological analysis of 103 patients

Objective  To improve management of ovarian metastasis through assessment of clinicopathological features and treatment outcomes associated with ovarian metastasis from colorectal cancer.
Method  We recruited 103 subjects who were diagnosed with ovarian metastasis and subjected to surgery between June 1989 and December 2005. Clinical and pathological variables were evaluated. Survival and its associated factors were analysed with a median follow-up of 31 months after ovarian surgery (range 1–129 months).
Results  The mean age at diagnosis was 46 years (range 14–72 years), synchronous ovarian metastasis occurred in 74 patients and metachronous in 29 patients. The primary tumour was more commonly associated with the colon rather than the rectum (84/1608, 5.2% vs 19/1534, 1.2%, P  <   0.001). Combined metastases occurred in 69 patients (67%). Complete resection was achieved in 34 (33%) patients without other metastases. The estimated 5-year disease free survival and overall survival rate were 40.1% and 26.6%, respectively. From univariate analysis, lymphovascular invasion (35.6% vs 12.8%, P  =   0.034), combined metastasis (50.9% vs 15.6%, P  =   0.0035) and bilaterale ovarian metastasis (36.4% vs 10.6%, P  =   0.015) were identified as significant poor prognosis factors, and from multivariate analysis combined metastasis and bilaterale ovarian metastasis were significant ( P  =   0.034 and P  =   0.015, respectively).
Conclusion  This study suggests a role for regular follow-up computed tomography scans within 6 months postoperatively and tumour marker assays for the early detection of ovarian metastasis in premenopausal women after primary surgery, especially in colonic patients with poor prognostic factors.     

Anorectal amelanotic melanoma

Objective  Anorectal melanoma is a rare, highly malignant tumour with a poor 5 year survival of 10%. Most anorectal melanomas have gross and/or histologic pigmentation, however about 30% of anorectal melanomas are amelanotic.
Method  We report three cases of amelanotic anorectal melanomas and integrate our data with six case reports of amelanotic malignant melanoma from the literature. Further we compare clinicopathological data and clinical outcome with large series of anorectal melanomas (both, amelanotic and pigmentated).
Results  There were seven females and two males, of median age 62 years (range: 45–75 years). Rectal bleeding was the leading symptom in all cases with a mean duration of 4 months before diagnosis. Eight of nine patients developed distant metastases. Median survival was 14 months (range: 3–60 months). A tumour thickness of < 4 mm was correlated with long-term disease-free survival, whereas tumour thickness of 4 mm or more was correlated with systemic recurrence.
Conclusion  Early diagnosis is key for efficient treatment and improved survival rate for patients with this unusual variant of melanoma. There is no difference in terms of age, time of diagnosis, stage and survival between pigmented and amelanotic anorectal melanoma.     

Differences in multidisciplinary team assessment and treatment between patients with stage IV colon and rectal cancer

Objective  At diagnosis, 14–27% of patients with colorectal cancer (CRC) have distant metastases (stage IV) and a poor prognosis. Today, treatment decisions for CRC patients are often made at multidisciplinary team (MDT) conferences. The aim of this study was to evaluate the effects of development and implementation of MDT assessment and treatment in patients with stage IV colon cancer (CC) and rectal cancer (RC) in a large population.
Method  All 1449 patients who had stage IV CRC at the time of diagnosis and were registered in the regional quality registry of Stockholm from 1995 to 2004 were included. Patients with CC and RC were grouped according to treatment and their characteristics were analysed separately.
Results  In total, 1000 patients with CC and 449 patients with RC had stage IV disease. Of these, 689 (68.9%) CC patients and 352 (78.4%) RC patients were assessed by a MDT and the proportion increased over the study period ( P  < 0.001). Surgery for metastases was undertaken on 39 (3.9%) CC patients and 38 (8.5%) RC patients ( P  < 0.001). CRC patients selected for metastasis surgery had 37% 5-year survival when compared with 2% in patients who were not selected for metastasis surgery ( P  < 0.001).
Conclusion  Patients with CC were less often assessed by a MDT and less often had metastasis surgery than RC patients. The proportion of patients with CC and RC assessed by a MDT increased during the study period, as did the proportion who had surgery for metastases. MDT assessment opens up the opportunity for more aggressive treatment with better outcomes.     

Clinical outcome of radical cystectomy for patients with pT4 bladder cancer

Objective:   The objective of this study was to analyze the outcomes of radical cystectomy for patients with pT4 bladder cancer.
Methods:   Between 1995 and 2003, 583 patients underwent radical cystectomy for bladder cancer at our institution and related hospitals, including 76 pathologically diagnosed as having pT4 disease. Of these 76, this study included 60 patients after excluding 16 with pT4Tis disease, and a retrospective review of their records was carried out.
Results:   Pathological examinations demonstrated that seven (11.6%) and 53 (88.4%) patients were Grades 2 and 3, respectively, and 48 (80.0%), 38 (63.4%), 10 (16.7%) and 30 (50.0%) were positive for lymphatic invasion, microvenous invasion, surgical margin and lymph node metastasis, respectively. During the observation period of this study (median, 24.5 months; range, 2–89 months), disease recurrence occurred in 38 (63.3%), and the median time to recurrence after radical cystectomy was 7.0 months (range, 1–38 months). One-, 3- and 5-year cancer-specific survival rates of the 60 patients were 68.8%, 48.5% and 23.9%, respectively. Univariate analysis identified lymph node metastasis, lymphatic invasion, microvenous invasion and positive surgical margin as significant predictors for cancer-specific survival; however, only lymph node metastasis was shown to be independently associated with cancer-specific survival by multivariate analysis.
Conclusions:   The prognosis of patients with pT4 bladder cancer is generally poor, particularly for those with nodal involvement. Therefore, it would be potentially important to carry out careful follow-up for such patients following radical cystectomy and, if necessary, to consider a multimodal therapeutic approach in an adjuvant setting.     

A comparison of segmental vs subtotal/total colectomy for colonic Crohn's disease: a meta-analysis

Purpose:  To evaluate differences in short- and long-term outcomes of patients with colonic Crohn's disease (CD) undergoing either subtotal/total colectomy with ileorectal anastomosis (IRA) or segmental colectomy(SC).
Method:  Comparative studies from 1988 to 2002, of subtotal/total colectomy and IRA vs SC, were used. The study end points included surgical and overall recurrence, time to recurrence, postoperative morbidity and incidence of permanent stoma. Meta-analytical tools were used to evaluate the study outcomes.
Results:  Six studies, consisting of a total of 488 patients (223-IRA and 265-SC) were included. Meta-analysis suggested no significant difference between IRA and SC in recurrence of CD. Time to recurrence was longer in the IRA group by 4.4 years (95%CI, 3.1–5.8), P  < 0.001. There was no difference in postoperative complications (OR = 1.4, 95%CI, 0.16–12.74) or the need for a permanent stoma between the two groups (OR = 2.75, 95%CI, 0.78–9.71). Patients with two or more colonic segments involved were associated with lower re-operation rate in the IRA group, a difference which did not reach statistical significance ( P =  0.177).
Conclusions:  Both procedures were equally effective as treatment options for colonic CD, however, patients in the SC group exhibited recurrence earlier than those in the IRA group. The choice of operation is dependent on the extent of colonic disease, with a trend towards better outcomes with IRA for two or more colonic segments involved.     

The effect of aspirin in the recurrence of colorectal adenomas: a meta-analysis of randomized controlled trials

Purpose  Colorectal adenomas are precursors of most colorectal cancers and are important targets for chemoprevention. Aspirin is thought to play an important role in chemoprevention. However, the role of aspirin in preventing recurrence of adenomas is controversial. We performed a systematic review and meta-analysis to evaluate the effect of aspirin in preventing the recurrence of colorectal adenoma.
Method  Trials were located through Medline, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL). From 14 articles screened, three were identified as randomized controlled trials and were included for data extraction. Main outcome measures were the recurrence of any new adenoma and advanced adenoma. The meta-analysis was performed with the fixed-effects model.
Results  A total of 2338 participants were enrolled in the three studies and 2175 of them completed the follow-up colonoscopy. We found that the relative risks of any adenoma (when compared with the placebo group) were 0.859 in the high dose of aspirin groups (95% confidence interval (CI), 0.756–0.976, P  = 0.019), 0.826 in the low dose of aspirin groups (95% CI 0.706–0.965, P  = 0.016) and 0.836 in the both aspirin combined groups (95% CI 0.746–0.937, P  = 0.002). For the recurrence of advanced adenoma, the relative risk (when compared with the placebo group) was 0.655 (95% CI 0.513–0.837, P  = 0.001) in the aspirin groups without considering the dose.
Conclusion  This meta-analysis suggests that aspirin prevents recurrent colorectal adenomas among patients with a history of colorectal adenomas.     

Effect of anaemia on mortality, cardiovascular hospitalizations and end-stage renal disease among patients with chronic kidney disease

Objective:   To determine whether an independent association exists between anaemia and chronic kidney disease (CKD) outcomes in a quasi-incidence cohort when patients' most recent laboratory values are considered.
Methods:   We conducted a dynamic, retrospective cohort study among patients with incident CKD in a large health maintenance organization administrative data set. CKD was defined by two estimated glomerular filtration rates (eGFR). We measured the absolute rates for all-cause mortality, cardiovascular hospitalizations and end-stage renal disease.
Results:   Our completed cases Cox regression model followed 5885 patients with both CKD and haemoglobin measures. For patients with the most severe anaemia (haemoglobin <10.5 g/dL), we estimated an increased rate of mortality (hazard ratio (HR) = 5.27, CI 4.37–6.35), cardiovascular hospitalizations (HR = 2.18, CI 1.76–2.70) and end-stage renal disease (HR = 5.46, CI 3.38–8.82) when compared with patients who were not anaemic; the HR reflect time-varying haemoglobins and eGFR.
Conclusion:   Anaemia is a predictor of excess mortality, excess cardiovascular hospitalizations and excess end-stage renal disease even when the progression of CKD is considered by controlling for time-varying eGFR values.     

Local Melanoma Recurrence: A Clarification of Terminology

Background. The current medical literature contains multiple different meanings for the term "local melanoma recurrence." Confusion regarding locally persistent and locally metastatic disease makes interpretation and analysis of previously published reports difficult if not impossible.
Objective. The objective was to present a more precise definition of local melanoma recurrence.
Methods. A case is reported and the literature is reviewed.
Conclusion. Owing to the myriad of different definitions that exist in the medical literature, the term "local melanoma recurrence" is ambiguous and at times misleading. Melanoma that recurs locally from persistence of tumor at the resection margins has a vastly different prognosis than recurrence developing from local (satellite) metastases adjacent to the surgical resection site. We propose the use of the terms "persistent melanoma" and "local metastasis" as more precise and predictive of a patient's prognosis.     

Family history? The forgotten question in high‐risk colorectal cancer patients

Aim  The aim of the study was to investigate the frequency and detail of family history recorded for patients diagnosed with potentially high-risk colorectal cancer, and to determine the proportion of these patients referred to a high-risk assessment clinic.
Method  Medical records of patients diagnosed with colorectal cancer under the age of 50 admitted to a major Sydney teaching hospital were reviewed. The proportion of records containing information about family history was calculated. Associations between recording of family history and demographic and clinical characteristics of patients were investigated. Logistic regression modelling was performed to identify significant, independent predictors of study outcomes.
Results  Of 113 patients with colorectal cancer diagnosed under the age of 50 years, 61 (54%, 95% CI: 44–63%) had an entry in their hospital medical record about family history. Family history was significantly less likely to be recorded for females, for those admitted via the Emergency Department, and for those with shorter lengths of stay. A significant family history was found in 51% of the 61 patients who had a family history recorded. Records of patients attending specialist colorectal surgeons were significantly more likely to contain information about family history than those who attended other specialists ( P  = 0.04). Only 14 patients (12%, 95% CI: 7–20%) were formally referred for further genetic assessment.
Conclusion  These results suggest that family history is still being neglected in routine clinical practice, and high-risk assessment services are underutilized, implying the need for further dissemination of guidelines with regard to the recognition and management of hereditary colorectal cancer.     

The cost-effectiveness of increasing kidney transplantation and home-based dialysis

Background:   Renal replacement therapy (RRT) consumes sizable proportions of health budgets internationally, but there is considerable variability in choice of RRT modality among and within countries with major implications for health outcomes and costs. We aimed to quantify these implications for increasing kidney transplantation and improving the rate of home-based dialysis.
Methods:   A multiple cohort Markov model was used to assess costs and health outcomes of RRT for new end-stage kidney disease (ESKD) patients in Australia for 2005–2010, using a health-care funder perspective. Patient characteristics and current practice patterns were based on the ANZDATA Registry. Two proposed changes were modelled: (i) increasing kidney transplants by between 10% and 50% by 2010; and (ii) increasing home haemodialysis (HD) and peritoneal dialysis (PD) to the highest rates observed among Australian centres. We assessed costs (Australian dollars), survival and quality-adjusted survival, and cost-effectiveness.
Results:   The number of new ESKD patients in 2010 was estimated to be 2700, with annual RRT costs of about $A700 million; cumulative costs (2005–2010) were $A5 billion. Increasing transplants by 10–50% saves between $A5.8 and $A26.2 million, and increases quality-adjusted life years (QALYs) by 130–658 QALYs. Switching new patients from hospital HD to (i) home HD saves $A46.6 million by 2010; or (ii) PD saves $A122.1 million.
Conclusions:   These clinical practice changes reduce costs, improve patient quality of life and, in the case of transplantation, increase survival. Planning for RRT services should incorporate efforts to maximize rates of transplantation and to encourage home-based over hospital-based dialysis to optimize cost-effectiveness in RRT service delivery.     

Prognostic factors of renal cell carcinoma with extension into inferior vena cava

Objective:   To evaluate the prognosis of our series of patients with renal cell carcinoma (RCC) and tumor thrombus involving inferior vena cava (IVC) treated with nephrectomy and thrombectomy.
Methods:   In 46 patients with unilateral RCC extending into IVC who underwent nephrectomy and thrombectomy (T3b in 38 patients, T3c in 6, T4 in 2, N+ in 15, M1 in 21), overall and cancer-specific survival rates were estimated, and the univariable and multivariable analysis were carried out to determine the prognostic factors among age, gender, performance status, fever, inflammatory laboratory parameters, nodal and distant metastasis, tumor thrombus level, pathological parameters and postoperative interferon-α administration.
Results:   The median age was 66.5 (range 35–79) years. The median follow-up was 18.0 (mean 36.7 ± 38.7) months. The overall and cancer-specific 5-year survival rates were 32.9% and 40.0%, respectively. The univariate analysis revealed that fever (hazard ratio: HR 4.03), C-reactive protein (HR 4.89), grade of tumor cell (HR 3.83), and lymph node metastasis (HR 5.99) were independent prognostic factors of cause-specific survival in all patients. The multivariate analysis demonstrated that lymph node metastasis (HR 4.13) was the only independent prognostic factor of cause-specific survival. The extension level or postoperative interferon-α administration did not influence the prognosis of patients with tumor thrombus involving IVC.
Conclusions:   Aggressive surgery should be considered first in RCC patients with any levels of tumor thrombus. However, patients with both IVC involvement and nodal metastasis showed significantly poor prognosis, and development of novel intensive multidisciplinary therapies will be needed.     

Prediction of bone metastases by combination of tartrate-resistant acid phosphatase, alkaline phosphatase and prostate specific antigen in patients with prostate cancer

Objective:   The clinical value of serum tartrate-resistant acid phosphatase (TRACP), prostate specific antigen (PSA), alkaline phosphatase (ALP), and prostatic acid phosphatase (PACP) for the prediction of bone metastases in prostate cancer were investigated.
Methods:   TRACP, PACP, ALP, and PSA serum levels were measured in 215 patients with prostate cancer, including 160 without and 55 with bone metastases. Correlation of serum marker levels with bone metastases was assessed using receiver operating characteristics (ROC) analysis. Sensitivity, specificity, accuracy, positive and negative predictive values were calculated for each serum marker. Multivariate stepwise logistic regression analysis was used to identify independent predictors for the presence of bone metastasis.
Results:   Mean serum TRACP, PACP, ALP, and PSA levels were significantly elevated in patients with bone metastases compared with those without ( P  < 0.05). PSA and PACP levels increased significantly with clinical stage of the disease, whereas TRACP and ALP levels only increased significantly in stage D2. Serum TRACP levels correlated significantly with extent of disease on bone scans. ROC analyses showed no significant differences in area under the curve for these markers. Logistic regression analysis demonstrated that PSA, ALP, and TRACP were significant predictors of bone metastasis. Predicted and observed risks of bone metastasis were well correlated when TRACP, ALP, and PSA were combined and bone scan could have been omitted in 70% of patients by assessing these three markers.
Conclusions:   Serum TRACP can be considered a useful predictor of bone metastases in prostate cancer. A combination of TRACP, ALP, and PSA can obviate the need for a bone scan in 70% of cases.     

Presentation and prognosis of local recurrence after total mesorectal excision

Objective  The aim of this study was to describe the presentation, treatment and prognosis of local recurrences following total mesorectal excision for rectal adenocarcinoma.
Method  Between 1999 and 2002, 201 patients were treated with total mesorectal excision for mid or low rectal cancer and were followed up prospectively.
Results  Overall 2-year survival was 85%. The 2-year recurrence rate was 8%. Eighteen patients developed local recurrence at 3–60 months.
Nine recurrences originated from the pelvic sidewall. These recurrences were symptomatic in 90% of patients. Only two patients were reoperated with a R0 resection and were alive without local recurrence after 19 and 31 months. The seven others died within 9 months.
Nine recurrences originated from an anastomotic suture line. Only two had symptoms. A R0 surgical resection was performed in all patients with a 67% sphincter conservation rate. After 26-months of median follow-up (range 7–58), all patients were alive.
Conclusion  Half of the local recurrence after total mesorectal excision was located at the anastomotic site. Rectoscopic examination should be performed regularly to detect these anatomotic recurrences that are accessible to a R0 itérative resection.     

Technical acquisition and dosimetric assessment of iodine-125 permanent brachytherapy in localized prostate cancer: Our first series of 100 patients

Objectives:   To assess our initial experience in the treatment of localized prostate cancer using low-dose-rate brachytherapy (LDR-brachytherapy) with iodine-125.
Methods:   One-hundred consecutive patients received LDR-brachytherapy between July 2004 and October 2006. Seventy-six patients were treated with seed implantation alone, whereas 24 patients were treated with a combination of brachytherapy and external beam radiotherapy. The minimal percentage of the dose received by 90% of the prostate gland (%D90), the percentage prostate volume receiving 100% of the prescribed minimal peripheral dose (V100), and the operation time were compared among every 10 consecutive patients.
Results:   The means of %D90 and V100 were 109.6% and 93.4%, respectively. When compared with the first 10 patients, both D90 and V100 showed significant improvement in the following 10 consecutive patients. Similarly, the mean operation time decreased significantly according to the accumulated number of patients.
Conclusions:   Our initial experience with the first 100 cases suggests that LDR-brachytherapy needs accumulation of many more patients to obtain high-quality post-implant dosimetric outcomes.     

Laparoscopic restorative proctocolectomy with and without previous subtotal colectomy

Introduction  Laparoscopic techniques have been applied to the procedure of restorative proctocolectomy (RPC). The aim of this study was to compare the outcomes of patients after laparoscopic ileal pouch-anal anastomosis (IPAA) with restorative proctocolectomy (RPC) and without previous colectomy [restorative proctectomy (RP)] and to highlight some technical tips.
Method  Data were collected prospectively from all patients who underwent laparoscopic IPAA from July 2006 to December 2007.
Results  Thirty-six patients underwent IPAA either with total proctocolectomy ( n  = 25) or after previous emergency colectomy ( n  = 11). Postoperative morbidity occurred in 22% of patients. The overall median operative time was 210 (range 120–325), 240 (170–325) and 180 (120–240) min for RPC and RP respectively ( P  < 0.05). The median length of stay for all patients was 6 (3–26), 6 (4–26) and 4 (3–13) days for RPC and RP respectively ( P  < 0.05). There was no correlation between BMI, age, use of immunosuppressive agents and length of stay. The operative procedure was facilitated by the use of specific devices at particular stages of the operation.
Conclusion  Laparoscopic IPAA is not only safe and feasible for the virgin abdomen but also for patients with a previous emergency colectomy through a midline laparotomy incision.     

The clinical characteristics of renal cell carcinoma in female patients

Objective:   To investigate the clinical characteristics of renal cell carcinoma (RCC) in female patients.
Methods:   The clinical characteristics including sex, age at diagnosis, histological tumor size, histological subtype, Fuhrman nuclear grade and pathological tumor–node–metastasis (TNM) stage of 881 consecutive patients treated with (partial) nephrectomy for RCC from 1998 to 2006 were analyzed. Characteristics of different gender groups and different female age groups were compared. The one-way anova and t -test were used to compare means. Pearson's χ²-test and the likelihood ratio test were used to compare ratios.
Results:   Low-grade tumors accounted for 79.3% of female patients and 64.1% of male patients ( P  < 0.001). The percentage of stage T1–2 was 76.6% in female patients while it was only 68.5% in male patients ( P  = 0.011). Also, female patients had more T1–2N0M0 tumors (73.0% vs 64.3%, P  = 0.009). Once female patients were classified into three groups according to age diagnosis (≤40, 41–59 and ≥60 years) young female patients seemed to have more tumors with unfavorable histology (8.7% vs 5.1% vs 4.3%), Fuhrman grade 3–4 (23.9% vs 23.1% vs 17.7%) and stage T3–4 (28.3% vs 23.1% vs 22.0%).
Conclusion:   Compared with male patients, female patients had lower stage and grade tumors. However, younger female patients had more tumors with unfavorable histology, and higher stage and grade compared to older female patients.     

Margin Involvement after the Excision of Melanoma In Situ: The Need for Complete En Face Examination of the Surgical Margins

BACKGROUND The standard treatment for cutaneous melanoma in situ is surgical excision followed by standard pathologic evaluation. Serial cross-sectioning (bread-loafing) may result in false negative margin examination and higher local recurrence rates than Mohs micrographic surgery, which histologically evaluates the entire surgical margin.
OBJECTIVE To estimate the sensitivity of bread-loafing in detecting residual melanoma in situ at surgical margins.
METHODS A retrospective study was performed including 36 cases of melanoma in situ treated with Mohs surgery with positive margins after initial excision with 5 mm margins. The length of the margin involved with melanoma was measured. The ability of bread-loafing to detect residual tumor was calculated.
RESULTS The average linear extent of tumor at the surgical margin was 1.4 mm. Bread-loafing at 1, 2, 4, and 10 mm intervals would have a 58, 37, 19, and 7% chance of detecting positive margins, respectively. In order to detect 100% of positive margins, bread-loafing would have to be performed every 0.1 mm.
CONCLUSION Bread-loaf cross-sections through excised melanoma specimens are inherently unreliable for detecting residual melanoma at the surgical margins. We recommend complete histologic margin control of the entire surgical margin using en-face tissue orientation (Mohs technique) to reduce the risk of recurrence.     

Rectal cancer with macroscopic peritoneal involvement – clinical challenges and consequences

Objective  In gastrointestinal cancer, serosal involvement indicates advanced disease. We looked at the possible role of clinical peritoneal involvement (CPI) in local recurrences (LRs) and the overall survival of patients with rectal cancer (RC).
Method  Between 1993 and 2002, 6404 patients were diagnosed with RC. Based on macroscopic findings at surgery and corresponding histological findings, 166 patients (3%) had CPI. Surgery was stratified according to type and extent of operation: as resective or nonresective surgery and as curative (R0) or noncurative (R1 or R2) resection.
Results  The presence of CPI was a negative factor for survival with a median of 15 months (95% CI, 12–19) in the presence of CPI compared with 65 months (95% CI, 61–70) without it ( P  < 0.001). In R0 resections, the median survival was 97 months (95% CI, 90–102) in patients without CPI compared with 48 months (95% CI, 22–74) in patients with CPI ( P  < 0.001). In R1 or R2 resections, the median survival was 16 months (95% CI, 15–17) in the absence of CPI and 9 months (95% CI, 8–10) in the presence of CPI. The LR rate in patients without CPI was 10.2% compared with 15.7% in patients with CPI ( P  = 0.022).
Conclusions  Clinical peritoneal involvement is a significant detrimental prognostic factor for the LR of RC and survival in the absence of metastases. Observations from this large national cohort add to what is known about peritoneal involvement. Diagnosed CPI should be taken into consideration when adjuvant treatment strategies are addressed.     

Role of lymph node density in predicting survival of patients with lymph node metastases after radical cystectomy: A multi-institutional study

Objectives:   To evaluate the prognostic role of different clinico-pathological parameters in node-positive patients treated by radical cystectomy.
Methods:   A retrospective multi-institutional study of 435 patients who underwent radical cystectomy between 1990 and 2005 was carried out. Of them, pathological lymph node (LN) metastases were found in 83 patients. Sixty of these 83 patients, whose clinical information and follow-up data were available, were included in the analysis. Twenty-five patients had undergone adjuvant chemotherapy, whereas 35 had not. A Cox proportional hazards model was used to determine the impact of the following clinico-pathological parameters on patient survival: number of resected LNs, number of positive LNs, LN density (defined as the ratio of the number of positive LNs divided by the total number of resected LNs) and adjuvant chemotherapy.
Results:   Median follow-up for surviving patients was 41 months (range 4–138) after surgery. The median survival time for all patients was 22 months (95% confidence interval, 15–42 months). At multivariate analysis, LN density of 25% or less, adjuvant chemotherapy and pure urothelial carcinoma were independently significant predictors of survival.
Conclusions:   Lymph node density predicts survival in patients with node-positive bladder cancer.     

The changing impact of age on colorectal cancer surgery. A trend analysis

Objective  The aim of the study was to evaluate the changing influence of age on the outcomes of colorectal cancer surgery in a retrospective trend analysis.
Methods  Data on 985 patients undergoing colorectal cancer surgery were collected during 1975–1984 and 1995–2004. Variables and outcomes of patients aged < 65, 65–74, 75–84 and 85+ years were compared with intra- and interdecade analyses. Endpoints of the study were postoperative mortality, 5-year overall and cancer-related survivals.
Results  The rate of elderly patients undergoing colorectal cancer surgery increased significantly from 1975–1984 to 1995–2004. Distribution of American Society of Anesthesiology score and cancer stage remained unchanged over time. The rate of palliative procedures decreased over time, most significantly in the older age groups. In 1995–2004 the palliation rate was similar across all age groups. The rate of emergency surgery also decreased, but it remained higher in older age groups. Operative mortality rate decreased over time across all age groups, but age-related differences were still observed in the 1995–2004 series. Cancer-related survival after curative surgery increased from 58% in 1975–1984 to 64% in 1995–2004 in 75+ years patients, while it increased from 56% to 78% in patients aged 74 years or younger.
Conclusions  Elderly patients with colorectal cancer benefited substantially from healthcare progress during the last 30 years. The reduction of palliative procedures and the decline in operative mortality document the efficacy of not restricting the access to radical surgery for these patients.