Lymphatic Staging in Colorectal Cancer: Pathologic, Molecular, and Sentinel Node Techniques

PURPOSE Accurate staging in colorectal cancer is important to predict prognosis and identify patients who could benefit from adjuvant therapy. Patients with lymphatic metastasis, Stage III/Dukes C, are generally treated with adjuvant chemotherapy. Still, patients without lymphatic metastasis do have relapse as high as 27 percent in five years in Dukes B2. It is hypothesized that these patients have occult (micro)metastasis in their lymph nodes. If these (micro)metastasis can be identified, these patients might benefit from adjuvant therapy. We reviewed the literature on procedures to improve lymph node staging.METHODS An extensive literature search was performed in PubMed (www.pubmed.com). Using the reference lists, more articles were found.RESULTS We found 30 articles about sentinel node in colorectal cancer describing original series. Some groups reported several studies including the same patients. We reported their largest studies. For all other techniques, we only included key articles.CONCLUSIONS Many techniques to improve staging have been described. The finding of occult (micro)metastasis is of prognostic significance in most studies. The sentinel node technique has been recently described for use in colorectal cancer. Although it seems clear that this technique has prognostic potential, it is not yet been shown in a follow-up study. Furthermore, the finding of occult (micro)metastasis in any technique used has not been shown to be clinically significant. Whether to treat patients with adjuvant therapy if occult (micro)metastasis are found needs to be proven in future studies.     

Colorectal cancer with neuroendocrine differentiation in a child

Colorectal cancer is extremely rare in children and presents with a poor prognosis because of the delay in diagnosis and lack of histological differentiation. We report a case of a sigmoid colon carcinoma with areas of neuroendocrine cells in a 12-year-old patient without familial occurrence of colorectal cancer. Symptoms at presentation were anaemia, anorexia, abdominal pain and weight loss. The patient was treated with radical resection and adjuvant chemotherapy. One year later, a local recurrence and hepatic metastases were diagnosed and she underwent chemotherapy and surgical resection. Twenty-six months from initial diagnosis she is alive with evidence of disease. The clinical presentation, diagnosis and treatment of the previously reported cases of colorectal cancer in children are also reviewed.     

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.     

Magnetic resonance colonography versus colonoscopy as a diagnostic investigation for colorectal cancer: a meta-analysis

AIMS: Magnetic resonance colonography (MRC) is emerging as a potential complementary investigation for the diagnosis of colorectal cancer (CRC) and also for benign pathology such as diverticular disease. A meta-analysis reporting the use of MRC is yet to be performed. The aim of this study was to evaluate the diagnostic accuracy of MRC compared with the gold-standard investigation, conventional colonoscopy (CC). METHODS: A literature search was carried out to identify studies containing comparative data between MRC findings and CC findings. Quantitative meta-analysis for diagnostic tests was performed, which included the calculation of independent sensitivities, specificities, diagnostic odds ratios, the construction of summary receiver operating characteristic (SROC) curves, pooled analysis and sensitivity analysis. The study heterogeneity was evaluated by the Q-test using a random-effect model to accommodate the cluster of outcomes between individual studies. RESULTS: In all, 8 comparative studies were identified, involving 563 patients. The calculated pooled sensitivity for all lesions was 75% (95% CI: 47% to 91%), the specificity was 96% (95% CI: 86% to 98%) and the area under the ROC curve was 90% (weighted). On sensitivity analysis, MRC had a better diagnostic accuracy for CRC than for polyps, with a sensitivity of 91% (95% CI: 97% to 91%), a specificity of 98% (95% CI: 66% to 99%) and an area under the ROC curve of 92%. There was no significant heterogeneity between the studies with regard to the diagnostic accuracy of MRC for CRC. CONCLUSION: This meta-analysis suggests that MRC is an imaging technique with high discrimination for cases presenting with colorectal cancer. The exact diagnostic role of MRC needs to be clarified (e.g. suitable for an elderly person with suspected CRC). Further evaluation is necessary to refine its applicability and diagnostic accuracy in comparison with other imaging methods such as computed tomography colonography.     

Automated mass detection in contrast-enhanced CT colonography: an approach based on contrast and volume

The purpose of this feasibility study was to design and test an algorithm for automating mass detection in contrast-enhanced CT colonography (CTC). Five patients with known colorectal masses underwent a pre-surgical contrast-enhanced (120 ml volume 1.6 g iodine/s injection rate, 60 s scan delay) CTC in high spatial resolution (16-slice CT: collimation: 16×0.75 mm, tablefeed: 24 mm/0.5 s, reconstruction increment: 0.5 mm). A CT-density- and volume-based algorithm searched for masses in the colonic wall, which was extracted before by segmenting and dilating the colonic air lumen and subtracting the inner air. A radiologist analyzed the detections and causes of false positives. All masses were detected, and false positives were easy to identify. Combining CT density with volume as a cut-off is a promising approach for automating mass detection that should be further refined and also tested in contrast-enhanced MR colonography. More information under .     

蛋白质酵母双杂交系统的建立及其在大肠癌肝转移研究中的意义

目的 建立酵母双杂交系统,筛选与FasL相互作用的蛋白,探讨FasL与大肠癌肝转移的关系。方法 以FasL基因构建诱饵蛋白质粒,筛选人胎肝cDNA文库,鉴定与FasL相互作用的蛋白,通过生物信息学分析FasL及其相互作用蛋白在大肠癌肝转移中的作用。结果 筛选出10个与FasL特异性相互作用的蛋白,包括金属硫蛋白1K、1G、2A,组织蛋白酶B,脂肪酸合成酶,干扰素α诱导蛋白27,磷脂清除酶,丝氨酸／苏氨酸样激酶,锚着黏附蛋白以及纤维微丝蛋白-5等。结论 成功建立了筛选FasL相互作用蛋白的酵母双杂交系统,并初步证明FasL与组织蛋白酶、金属硫蛋白、锚着黏附蛋白等之间的相互作用与大肠癌肝转移密切相关。     

Comparison of resource utilization and long-term quality-of-life outcomes between laparoscopic and conventional colorectal surgery

Background The outcomes of laparosopic and conventional colorectal surgery, with special reference to costs of treatment and patients' quality of life, were compared. Methods A partly retrospective cohort study was designed to assess the use of resources, and a follow-up interview was undertaken to evaluate patients' quality of life after both to define laparoscopic (LAP) and conventional (CON) surgery. Results The length of hospital stay was significantly lower in the LAP group (median, 11 days; interquartile range [IQR], 9–15) than in the CON group (median, 16 days; IQR, 13–23; p < 0.0001), which is reflected in lower costs of hospitalization calculated for the three most frequent surgical interventions. Statistically significant improvements were noted between the median scores in the domains of physical functioning (LAP 85 vs CON 68; p < 0.05) and vitality (LAP 85 vs CON 69; p < 0.05). Conclusion Laparoscopy is a promising alternative for the treatment of patients with colorectal diseases, offering lower costs and a better quality of life in the long term.     

Use of the surgical towel in colorectal hand-assisted laparoscopic surgery (HALS)

The use of laparotomy pads or towels to displace the small intestine away from the operative site is a well-established technique in open surgery; however, its application is unfeasible or extremely challenging in standard laparoscopic surgery. We describe the use of standard surgical towels in hand-assisted laparoscopic surgery (HALS). A Pfannenstiel incision is made and a Gelport hand-access device is assembled. A sterilized surgical towel, 65 × 44 cm in size, is inserted via the Gelport, unfolded, and placed over the bowel loops laparoscopically with the assistance of the hand. The bowel loops are then housed gently in the towel and displaced away from of the operative site. HALS enables the easy insertion and handling of a large surgical towel inside the peritoneal cavity. The towel successfully retracts the small intestine, enabling the surgeon to concentrate the use of his or her hand on the targeted structures. This practical and inexpensive tip adds another advantageous component to the practice of colorectal HALS.     

Laparoscopic total mesorectal excision (TME) for rectal cancer surgery: long-term outcomes

Background: Total mesorectal excision (TME) offers the lowest reported rates of local recurrence and the best survival results in patients with rectal cancer. However, the laparoscopic approach to resection for colorectal cancer remains controversial due to fears that oncologic principles will be compromised. We assessed the feasibility, safety and long-term outcome of laparoscopic rectal cancer resections following the principles of TME. The aim of this study was to evaluate the perioperative outcome and long-term results of laparoscopic TME. Methods: We reviewed the prospective database of 102 consecutive unselected patients undergoing laparoscopic TME for rectal cancer between November 1991 and December 2000. Follow-up was done through office charts or direct patient contact. Recurrence and survival curves were generated by the Kaplan-Meier method. Results: Laparoscopic TME was completed successfully in 99 patients, whereas conversion to an open approach was required in three cases (3%). The overall morbidity and mortality rates were 27% and 2%, respectively, with an overall anastomotic leak rate of 17%. Of the 102 patients, four were excluded from the oncologic evaluation because final pathology was not confirmatory (two had anal canal squamous cell carcinoma and two had villous adenoma with dysplasia). In 90 of the 98 remaining patients (91.8%), the resection was considered curative. The remainder had a palliative resection due to synchronous metastatic disease or locally advanced disease. Mean follow-up was 36 months (range, 6–96). There were no trocar site recurrences. The local recurrence rate was 6%, and the cancer-specific survival of all curatively resected patients was 75% at 5 years. The overall survival rate of all curatively resected patients was 65% at 5 years; mean survival time was 6.23 years (95% confidence interval [CI], 5.39–7.07). Conclusion: Laparoscopic TME is feasible and safe. The laparoscopic approach to the surgical treatment of operable rectal cancer does not seem to entail any oncologic disadvantages. Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), New York, NY, USA, 13–16 March 2002     

Laparoscopic colorectal surgery in obese and nonobese patients: Do differences in body mass indices lead to different outcomes?

Background The aim of this prospective study was to compare the outcome of laparoscopic colorectal surgery in obese and nonobese patients.Methods All patients who underwent laparoscopic surgery for both benign and malignant disease within the past 5 years were entered into the prospective database registry. Body mass index (BMI; kg/m²) was used as the objective measure to indicate morbid obesity. Patients with a BMI >30 were defined as obese, and patients with a BMI <30 were defined as nonobese. The parameters analyzed included age, gender, comorbid conditions, diagnosis, procedure, duration of surgery, transfusion requirements, conversion rate, overall morbidity rate including major complications (requiring reoperation), minor complications (conservative treatment) and late-onset complications (postdischarge), stay on intensive case unit, hospitalization, and mortality. For objective evaluation, only laparoscopically completed procedures were analyzed. Statistics included Students t test and chi-square analysis. Statistical significance was assessed at the 5% level (p < 0. 05 statistically significant).Results A total of 589 patients were evaluated, including 95 patients in the obese group and 494 patients in the nonobese group. There was no significant difference in conversion rate (7.3% in the obese group vs 9.5% in the nonobese group, p > 0.05) so that the laparoscopic completion rate was 90.5% (n = 86) in the obese and 92.7% (n = 458) in the nonobese group. The rate of females was significantly lower among obese patients (55.8% in the obese group vs 74.2% in the nonobese group, p = 0.001). No significant differences were observed with respect to age, diagnosis, procedure, duration of surgery, and transfusion requirements (p > 0.05). In terms of morbidity, there were no significant differences related to overall complication rates with respect to BMI (23.3% in the obese group vs 24.5% in the nonobese group, p > 0.05). Major complications were more common in the obese group without showing statistical significance (12.8% in the obese group vs 6.6% in the nonobese group, p = 0.078). Conversely, minor complications were more frequently documented in the nonobese group (8.1% in the obese group vs 15.5% in the nonobese group, p = 0.080). In the postoperative course, no differences were documented in terms of return of bowel function, duration of analgesics required, oral feeding, and length of hospitalization (p > 0.05).Conclusion These data indicate that laparoscopic colorectal surgery is feasible and effective in both obese and nonobese patients. Obese patients who are thought to be at increased risk of postoperative morbidity have the similar benefit of laparoscopic surgery as nonobese patients with colorectal disease.