Guidelines 2000 for colon and rectal cancer surgery

Colon cancer management and outcome in relation to individual hospitals in a defined population

Background

The Stockholm and Gotland region in Sweden has a common management protocol for the treatment of colon cancer. The aim of this study was to assess the management and treatment of colon cancer in the region and to try to identify ways to improve the outcome further.

Methods

Clinical data on all patients diagnosed with colon cancer in the region's nine hospitals between January 1996 and December 2000 were prospectively collected. Patients were followed until December 2004, and their management and outcome analysed.

Results

Colon cancer was diagnosed in 2775 patients. An elective operation was performed in 2116 (76·3 per cent) patients and an emergency procedure in 590 (21·3 per cent). Emergency surgery was an independent risk factor for death. The crude overall cumulative 5-year survival was 46·2 per cent. A multivariable analysis of risk of dying and risk of local recurrence showed significant differences between hospitals. The number of lymph nodes examined in the specimens also differed between hospitals.

Conclusion

Differences in the management and outcome of colon cancer in the nine hospitals, despite a common management protocol, indicate a need for improving collaboration between hospitals and multidisciplinary management.

Potential prognostic benefit of lateral pelvic node dissection for rectal cancer located below the peritoneal reflection

OBJECTIVE

To identify the parameters related to the effective selection of patients who could receive prognostic benefit from lateral pelvic node dissection.

BACKGROUND

Accurate preoperative diagnosis of lateral nodal involvement (LNI) remains difficult, and the indications for lateral lymph node dissection have been controversial.

PATIENTS AND METHODS

A total of 244 consecutive patients who underwent potentially curative surgery with lateral dissection for advanced lower rectal cancer (1985-2000) were reviewed. Patients were stratified into groups based on various parameters, and the therapeutic value index for survival benefit was compared among groups. The therapeutic index of lateral dissection was calculated by multiplying the frequency of metastasis to the lateral area and the cancer-related 5-year survival rate of patients with metastasis to the lateral area, irrespective of metastasis to other areas (mesorectal, superior rectal artery [SRA], and inferior mesenteric artery [IMA] areas).

RESULTS

LNI was observed in 41 patients (17%); and 88% of them had nodal involvement in the region along the internal iliac/pudendal artery or in the obturator region ("vulnerable field"). The cancer-related 5-year survival rate among the patients with LNI was 42%; the therapeutic index for lateral dissection was calculated as 7.0 patients, which was much higher than that of lymphadenectomy of the SRA area (1.6 patients) and the IMA area (0.4 patients), and almost comparable to that of lymphadenectomy of the upward mesorectal area (6.9 patients). Although it was possible to select groups at high and low risk for LNI based on several parameters related to tumor aggressiveness, such as tumor differentiation in biopsy specimens, the therapeutic value index was not significantly different between these groups. Unlike these parameters, the diameter of the largest lymph node in the "vulnerable field," which was positively correlated with the rate of LNI but irrelevant to the prognosis, was able to successfully stratify patients by therapeutic index.

CONCLUSIONS

Advanced lower rectal cancer patients having LNI in the lateral pelvic area are likely to receive prognostic benefit from lymphadenectomy. The most efficient means of determining the effectiveness of lateral dissection preoperatively is to estimate the nodal diameter in the "vulnerable" lateral regions by diagnostic imaging.

Laparoscopic approach to colonic cancer: critical appraisal of the literature

BACKGROUND/AIMS

As laparoscopic colectomy finds its place in the surgical armamentarium, the literature concerning the safety, efficacy, and oncological rational for treatment of colonic cancer is also enriched. A review and critical appraisal of the literature on this subject was the aim of this paper.

METHODS

A systematic research and a hand search were conducted to gain access to all controlled studies involving laparoscopic colectomy using the Medline, Embase, HealthSTAR, Cumulative Index for Nursing and Allied Health Literature, CancerLit data bases and the Cochrane Central Register of Controlled Trials for the years 1991-2006.

RESULTS

Over 40 controlled randomized trials and ten systematic reviews and/or meta-analyses were found. Several of the completed controlled randomized trials have published either short- or long-term results; only partial and short-term results are available in rectal cancer. The principal conclusions are that the laparoscopic approach affords better short-term outcomes including surgical site morbidity, but with increased operative times and direct costs. Among the proven long-term outcomes, cancer recurrence and survival do not seem to be worse. Whether conversion, a source of increased operative time and costs, is responsible for poorer outcomes or whether specific settings associated with poorer outcomes are among the causes of conversion remains to be shown. However, there are still concerns as regards specific laparoscopic-related complications.

CONCLUSION

There seems to no real safety problems in performing laparoscopic colectomy for cancer; improvement in operative times, conversion rates, and complications should make laparoscopy the best cost-effective approach to colectomy.

Instrumental clinical restaging, pathological evaluation, and tumor regression grading: how to assess the response to neoadjuvant chemoradiotherapy for rectal cancer

INTRODUCTION

The object of neoadjuvant chemoradiotherapy regimens is a downstaging or downsizing of advanced rectal tumor to increase the rate of curative resection and reduce loco-regional failure. A reliable method of assessing response to adjuvant therapies is required to help standardize the assessments of new multimodality therapies. The purpose of this study was to evaluate the role played by tumor regression grading on the evaluation of pathological response to chemoradiotherapy, compared with both the predicting value of the clinical response to neoadjuvant therapy and pathologic response evaluation.

METHODS

From 1994 to 2003, 58 patients with a primary diagnosis of rectal cancer were studied at our department and enrolled in a single center, not randomized study based on 5-week sessions of radiotherapy associated with a 30-day 5-fluorouracil (FU) infusion, followed by surgical resection. Instrumental restaging and routine histological examination, including tumor regression grading, were performed to asses the response to neoadjuvant therapy.

RESULTS

The cCR rate corresponds to pCR rate, while a 3.5% of cPR and a 3.4% of cSD corresponded to a pPD. cPR and cSD show a PPV of 92.8% and 90.9% respectively, while cPD NPV is 20%. No case was found with no regression (grade 0). Tumor regression was defined grade 1 in 24.5% of cases, grade 2 was found in 58.5% of cases, 7.5% were grade 3, and 9.5% showed complete regression (grade 4). Pathologic response resulted to be associated with regression grade (p=0.006). Tumor regression grading is an independent variable for pT (p=0.0002), pN status (p=0.00004), pathologic staging (p=0.000001) and local recurrence (p=0.003).

CONCLUSION

Our results lead us to consider only pathologic evaluation to determine the response to neoadjuvant treatment: the application of tumor regression grading on the specimens obtained after combined neoadjuvant chemoradiotherapy and surgery is useful to plan a better therapeutic strategy on the ground of a quantitative evaluation of the response to neoadjuvant treatment; it shows it is an important comparable pathological feature, useful in comparing different protocols' results and differences between patient's response as well as prognostic factors.

Patterns of failure and survival for nonoperative treatment of stage c0 distal rectal cancer following neoadjuvant chemoradiation therapy

Neoadjuvant chemoradiation therapy (CRT) is the preferred treatment option for distal rectal cancer. Complete pathological response after CRT has led to the proposal of nonoperative approach as an alternative treatment for highly selected patients with complete clinical response. However, patterns of failure following this strategy remains undetermined. Three hundred sixty-one patients with distal rectal cancer were managed by neoadjuvant CRT including 5-FU, leucovorin, and 5040 cGy. Tumor response assessment was performed at 8 weeks following CRT. Patients with complete clinical response were not immediately operated on and were closely followed. One hundred twenty-two patients were considered to have complete clinical response after the first tumor response assessment. Of these, only 99 patients sustained complete clinical response for at least 12 months and were considered stage c0 (27.4%) and managed nonoperatively. Mean follow-up was 59.9 months. There were 13 (13.1%) recurrences: 5 (5%) endorectal, 7 (7.1%) systemic, and 1 (1%) combined recurrence. All 5 isolated endorectal recurrences were salvaged. Mean recurrence interval was 52 months for local failure and 29.5 months for systemic failure. There were five cancer-related deaths after systemic recurrences. Overall and disease-free 5-year survivals were 93% and 85%. Even though surgery remains the standard treatment for rectal cancer, nonoperative treatment after complete clinical response following neoadjuvant CRT may be safe and associated with good survival rates in a highly selected group of patients. Survival in these patients is significantly affected by systemic failure. Exclusive local failure occurs late after CRT completion and is frequently amenable to salvage therapy.

Tumor invasion of lymph node capsules in patients with Dukes C colorectal adenocarcinoma

PURPOSE

The objective of this study was to investigate the correlation between the microscopic findings of positive lymph nodes, especially focusing on capsular invasion, and the outcome after curative surgical resection of colorectal cancer.

METHODS

We analyzed 480 positive lymph nodes from 155 consecutive patients with Stage III colorectal cancer to determine the frequency and significance of lymph node capsular invasion. Recurrence-free and cancer-specific survival rates were assessed in the patients with and without lymph node capsular invasion.

RESULTS

Between April 1995 and December 2000, 406 consecutive patients with primary colorectal cancer underwent curative resection. Regional lymph node metastases were present in 155 cases (38.2 percent). During the median follow-up period of 4.8 years, 41 patients (26.5 percent) developed recurrent disease and 28 patients died of cancer. Lymph node capsular invasion was detected in one or more lymph nodes from 75 cases (48.3 percent). The five-year recurrence-free rate was 56.1 percent in this group, whereas in the 80 patients without lymph node capsular invasion the rate was 88 percent (P<0.01). Features that were associated with recurrent disease were greater number of positive lymph nodes, venous invasion in primary tumor, infiltrative growth pattern of intranodal tumor, and presence of lymph node capsular invasion. Multivariate analysis identified lymph node capsular invasion as the only significant prognostic factor for recurrence. In multivariate analysis with regard to survival, lymph node capsular invasion, venous invasion, and number of positive nodes remained as significant prognostic factors.

CONCLUSIONS

Lymph node capsular invasion, determined by routine hematoxylin-eosin staining, is a potent prognostic factor in Stage III colorectal cancer.

Patterns of failure and survival for nonoperative treatment of stage c0 distal rectal cancer following neoadjuvant chemoradiation therapy

Neoadjuvant chemoradiation therapy (CRT) is the preferred treatment option for distal rectal cancer. Complete pathological response after CRT has led to the proposal of nonoperative approach as an alternative treatment for highly selected patients with complete clinical response. However, patterns of failure following this strategy remains undetermined. Three hundred sixty-one patients with distal rectal cancer were managed by neoadjuvant CRT including 5-FU, leucovorin, and 5040 cGy. Tumor response assessment was performed at 8 weeks following CRT. Patients with complete clinical response were not immediately operated on and were closely followed. One hundred twenty-two patients were considered to have complete clinical response after the first tumor response assessment. Of these, only 99 patients sustained complete clinical response for at least 12 months and were considered stage c0 (27.4%) and managed nonoperatively. Mean follow-up was 59.9 months. There were 13 (13.1%) recurrences: 5 (5%) endorectal, 7 (7.1%) systemic, and 1 (1%) combined recurrence. All 5 isolated endorectal recurrences were salvaged. Mean recurrence interval was 52 months for local failure and 29.5 months for systemic failure. There were five cancer-related deaths after systemic recurrences. Overall and disease-free 5-year survivals were 93% and 85%. Even though surgery remains the standard treatment for rectal cancer, nonoperative treatment after complete clinical response following neoadjuvant CRT may be safe and associated with good survival rates in a highly selected group of patients. Survival in these patients is significantly affected by systemic failure. Exclusive local failure occurs late after CRT completion and is frequently amenable to salvage therapy.

A human colon cancer cell capable of initiating tumour growth in immunodeficient mice

Colon cancer is one of the best-understood neoplasms from a genetic perspective, yet it remains the second most common cause of cancer-related death, indicating that some of its cancer cells are not eradicated by current therapies. What has yet to be established is whether every colon cancer cell possesses the potential to initiate and sustain tumour growth, or whether the tumour is hierarchically organized so that only a subset of cells--cancer stem cells--possess such potential. Here we use renal capsule transplantation in immunodeficient NOD/SCID mice to identify a human colon cancer-initiating cell (CC-IC). Purification experiments established that all CC-ICs were CD133+; the CD133- cells that comprised the majority of the tumour were unable to initiate tumour growth. We calculated by limiting dilution analysis that there was one CC-IC in 5.7 x 10(4) unfractionated tumour cells, whereas there was one CC-IC in 262 CD133+ cells, representing >200-fold enrichment. CC-ICs within the CD133+ population were able to maintain themselves as well as differentiate and re-establish tumour heterogeneity upon serial transplantation. The identification of colon cancer stem cells that are distinct from the bulk tumour cells provides strong support for the hierarchical organization of human colon cancer, and their existence suggests that for therapeutic strategies to be effective, they must target the cancer stem cells.

Development of Quality Indicators for Patients Undergoing Colorectal Cancer Surgery

BACKGROUND

Colorectal cancer is the second most common cancer type among new cancer diagnoses in the United States. Attention to the quality of surgical care for colorectal cancer is of particular importance given the increasing numbers of colorectal cancer resections performed in the aging population. A National Cancer Institute-sponsored consensus panel produced guidelines for colorectal cancer surgery in 2000. We have updated and extended that work by using a formal process to identify and rate quality indicators as valid for care during the preoperative, intraoperative, and postoperative periods.

METHODS

Using a modification of the RAND/UCLA Appropriateness Methodology, we carried out structured interviews with leaders in the field of colorectal cancer surgery and systematic reviews of the literature to identify candidate quality indicators addressing perioperative care for patients undergoing surgery for colorectal cancer. A panel of 14 colorectal surgeons, general surgeons, and surgical oncologists then evaluated and formally rated the indicators using the modified Delphi method to identify valid indicators.

RESULTS

A total of 142 candidate indicators were identified in six broad domains: privileging (which addresses surgical credentials), preoperative evaluation, patient-provider discussions, medication use, intraoperative care, and postoperative management. The expert panel rated 92 indicators as valid. These indicators address all domains of perioperative care for patients undergoing surgery for colorectal cancer.

CONCLUSIONS

The RAND/UCLA Appropriateness Methodology can be used to identify and rate indicators of high-quality perioperative care for patients undergoing surgery for colorectal cancer. The indicators can be used as quality performance measures and for quality-improvement programs.

More extensive nodal dissection improves survival for stages I to III of colon cancer: a population-based study

OBJECTIVE

To determine whether analyzing more lymph nodes in colon cancer specimens improves survival.

SUMMARY BACKGROUND DATA

Increasing the number of lymph nodes analyzed has been reported to correlate with improved survival in patients with node-negative colon cancer.

METHODS

The Surveillance, Epidemiology, and End Results database was queried for all patients undergoing resection for histologically confirmed colon cancer between the years 1988 and 2000. Patients were excluded for distant metastases or if an unknown number of nodes was sampled. The number of nodes sampled was categorized into 0, 1 to 7, 8 to 14, and > or =15 nodes. Survival curves constructed using the Kaplan-Meier method were compared using log rank testing. A Cox proportional hazard model was created to adjust for year of diagnosis, age, race, gender, tumor grade, tumor size, TNM stage, and percent of nodes positive for tumor.

RESULTS

The median number of lymph nodes sampled for all 82,896 patients was 9. For all stages examined, increasing nodal sampling was associated with improved survival. Multivariate regression demonstrated that patients who had at least 15 nodes sampled as compared with 1 to 7 nodes experienced a 20.6% reduction in mortality independent of other patient and tumor characteristics.

CONCLUSIONS

Adequate lymphadenectomy, as measured by analysis of at least 15 lymph nodes, correlates with improved survival, independent of stage, patient demographics, and tumor characteristics. Currently, most procedures do not meet this guideline. Future trials of adjuvant therapy should include extent of lymphadenectomy as a stratification factor.

Patterns of lateral pelvic lymph node metastases and micrometastases for patients with lower rectal cancer

AIMS

We aimed at investigating the patterns of lymph node metastases and micrometastases in regions of lateral pelvic area, examining circumferential margin involvement and clarifying their prognostic significance.

METHODS

Large tissue slice and tissue array were adopted in the study of 67 patients with AJCC stages I-III lower rectal cancer who underwent total mesorectal excision with systematic lateral pelvic dissection. The outcomes were followed.

RESULTS

Altogether, 726 lateral lymph nodes were examined, with 32 and 38 were involved by tumor metastases and micrometastases, respectively. Fifty-eight (82.9%) of the involved lymph nodes were smaller than 5mm. Status of lateral nodes was related to that of mesorectal ones. Middle rectal root (45.5%), internal iliac (31.8%) and obturator (22.7%) regions were more likely to be involved by metastases. Patients with lateral metastases, similar to the group with micrometastases, suffered more recurrence and poorer survival when compared with the ones without metastases. The occurrence of circumferential margin involvement suggested poor prognosis and was related to lateral node status.

CONCLUSIONS

In lateral pelvic area, the majority of lymph nodes harboring tumor were small and could easily be neglected by conventional examination. Incidence of lateral metastases differed among regions, thus more attention should be given to the clearance of the highly occurred areas. More extensive range of dissection and/or adjuvant therapy was recommended for patients with lateral node metastases, micrometastases and circumferential margin involvement, since they predisposed poor prognosis.

Minimally invasive management of colon cancer

One of the most controversial issues in minimally invasive surgery has been the implementation of laparoscopic techniques for the curative resection of colorectal malignancies. Initial concerns included the potential violation of oncologic principles, the effects of carbon dioxide, and the phenomenon of port site tumor recurrence. Basic science research and large randomized controlled trials are now demonstrating that these fears were unjustified. Long-term outcomes of laparoscopic colon resection compared with open colon resection for malignancy are comparable, and there may even be a survival benefit for a subset of patients who undergo laparoscopic resection.

Results of an aggressive approach to resection of locally recurrent rectal cancer

BACKGROUND

The value of resection for locally recurrent rectal cancer (LRRC) remains controversial. We analyzed outcomes of an aggressive approach to resection of LRRC.

METHODS

We conducted a retrospective chart review of 52 consecutive patients who underwent resection of LRRC from September 1997 through August 2005. Overall and disease-free survival (OS, DFS) curves were constructed by the Kaplan-Meier method, and compared by log-rank analysis. Median follow-up time was 29 months (range 3-72).

RESULTS

Thirty-one patients (60%) were male. Median age was 60 years (range 36-88). Forty-six of the 52 patients were resected with curative intent, while 6 had known distant metastases at the time of resection. All 52 patients underwent grossly complete resection of local disease, and 41 (79%) had microscopically clear resection margins. An en bloc sacrectomy was performed in 28 (54%) patients. Postoperative mortality was nil; significant complications developed in 42% of patients. The complication rate was higher in patients with sacrectomy than without (50 vs. 33%, P = 0.017, Chi square). For the entire cohort of 52 patients, median OS and DFS were 40 and 24 months, respectively. Survival was equivalent in patients with and without sacrectomy. In the 46 patients who had resection with curative intent, 4-year OS was 48%. Median OS in the six patients with distant metastases at the time of resection was 21 months. OS was predicted by the presence of metastases (P = 0.01), and margin status (P < 0.0001). DFS was predicted by margin status (P = 0.0001).

CONCLUSIONS

In this series of patients who underwent resection of LRRC, microscopic margin status was the most significant predictor of OS and DFS. Requirement for en bloc sacrectomy was not associated with inferior survival. Carefully selected patients with distant metastases may benefit from resection of LRRC.

Population-based assessment of the surgical management of locally advanced colorectal cancer

BACKGROUND

Evidence-based guidelines recommend multivisceral resection for patients with locally advanced adherent colorectal cancer because it reduces local recurrence and improves survival. However, this procedure can increase morbidity compared with standard resection and may not be practiced uniformly. We performed a population-based study to examine surgical practice and outcomes among patients with locally advanced adherent colorectal cancer in the United States.

METHODS

Patients who were 18 years or older and who had surgical resection for nonmetastatic, locally advanced adherent colorectal cancer from January 1, 1988, through December 31, 2002, were identified from the Surveillance, Epidemiology, and End Results (SEER) registry. Logistic regression was used to examine patient, tumor, and geographic factors associated with multivisceral resection. Cumulative early mortality (i.e., at 1 and 6 months after diagnosis) and 5-year survival were obtained from Kaplan-Meier estimates; adjusted risks of death were calculated using Cox proportional hazards models. All statistical tests were two-sided.

RESULTS

We identified 8380 patients who underwent surgical resection for locally advanced adherent colorectal cancer, of whom 33.3% were managed with multivisceral resection. Among colon cancer patients, younger age at diagnosis, female sex, SEER region, node negativity, and left-sided tumors were independently associated with having had a multivisceral resection. Among rectal cancer patients, younger age at diagnosis and female sex were positively and statistically significantly associated with multivisceral resection, whereas receipt of neoadjuvant radiation was inversely and statistically significantly associated with multivisceral resection. Compared with standard resection, multivisceral resection was associated with improved overall survival for patients with colon (hazard ratio [HR] = 0.89, 95% confidence interval [CI] = 0.83 to 0.96) and rectal (HR = 0.81, 95% CI = 0.70 to 0.94) cancer, with no associated increase in early mortality.

CONCLUSIONS

The majority of patients with locally advanced colorectal cancer did not receive a multivisceral resection. The geographic variation in the application of this procedure in patients with colon cancer suggests that local organizational structures and processes of care may play an important role in patient treatment and, therefore, prognosis.

Number of Lymph Nodes Examined and its Impact on Colorectal Cancer Staging

The status of lymph nodes is the most important prognosticator in colorectal cancer patients. Patients with lymph node involvement have a lower survival rate and are candidates for adjuvant therapy. The purpose of our study was to determine the number of lymph nodes that needs to be examined to accurately detect nodal metastasis. We conducted a retrospective study of 151 patients who underwent colorectal cancer operation at Harbor-UCLA Medical Center. Data from the operative report and pathology report were collected and analyzed. Fourteen (33.3%) patients with five to nine nodes examined had positive nodes. Twenty-six (57.8%) patients with 10 to 14 nodes examined had positive nodes. Patients who had 10 to 14 nodes examined were significantly more likely to have positive lymph nodes (P = 0.03). Patients with advanced T stage had a significantly higher number of positive lymph nodes (78.1% in T4 vs 11.1% in T1, P < 0.0001). Patients with poorly differentiated cancer showed a trend toward a higher positive node rate. Tumor differentiation and T stage seem to correlate with higher nodal metastasis rate. A higher number of lymph nodes examined was associated with a higher nodal metastasis rate. Examination of at least 10 lymph nodes would increase the yield of positive lymph nodes and avoid under-staging of patients with colorectal cancer.

Retroperitoneal and Lateral Pelvic Lymphadenectomy Mapped by Lymphoscintigraphy and Blue Dye for Rectal Adenocarcinoma Staging: Preliminary Results

BACKGROUND

Total mesorectal excision (TME) is the standard surgical choice for rectal adenocarcinoma. Better prognostic results, achieved with a retroperitoneal and lateral pelvic lymphadenectomy (RLPL), have questioned that TME might not be satisfactory for adequate patient staging, affecting therapeutic definitions. The aims of the ongoing study are to define the accuracy of dye and probe search in the detection of metastatic retroperitoneal and lateral pelvic nodes (RLPN) resected with RLPL, and to evaluate the metastasis frequency in these nodes and its eventual upstaging impact.

METHODS

Thirty rectal adenocarcinoma patients were submitted to RLPL, with RLPN mapping using technetium (Tc 99 m) and patent blue, having nodes examined histopathologically and immunohistochemically.

RESULTS

Eight hundred and two nodes were analyzed, mean of 26.7 per patient; RLPL was responsible for 41% (330) of the examined nodes, mean of 11 per patient. Metastatic RLPN have occurred in 20% of the patients; the RLPN were metastatic in only 6.7% of the patients; RLPL upstaged 13.3%. For identification of metastatic RLPN with technetium, sensitivity was 33%, specificity 79%, positive predictor value (PPV) 29%, negative predictor value (NPV) 83% and false negative (FN) rate 67%. For patent blue and technetium metastatic RLPN identification, sensitivity was 17%, specificity 92%, PPV 33%, NPV 82% and FN 83%.

CONCLUSIONS

Preliminary results have pointed out technetium and blue dye low accuracy to identify metastatic RLPN; no metastatic RLPN were reported in the patients submitted to preoperative chemoradiation and important upstaging with RLPL. Considering no increase in morbi-mortality rates with RLPL, definitive conclusions will be obtained as the study carries on.

Surgical outcomes after total mesorectal excision for rectal cancer

BACKGROUND AND OBJECTIVES

This study reviewed the results of surgery for distal rectal cancer following the introduction of total mesorectal excision (TME) for rectal cancer.

METHODS

Two hundred sixty-four patients who had undergone elective curative surgical resection of rectal cancer within 12 cm of the anal verge were included. Comparisons were made between patients who had different surgical procedures.

RESULTS

The overall operative mortality rate was nil, and the morbidity 39.4%. With a mean follow-up of 34 months (range 5-105 months), local recurrence occurred in 21 of the patients. The 3- and 5-year actuarial local recurrence rates were 9% and 12%, respectively for the whole group. Abdominoperineal resection (APR) was necessary in 65 of 264 (24.6%) of the patients, with a very low local recurrence rate in this subgroup (5% at 3 years). On multivariate analysis, only stage was a significant prognosticator of overall survival (P = 0.012).

CONCLUSIONS

With the practice of TME, APR was still necessary in 25% of patients with rectal cancer within 12 cm of the anal verge. Type of surgery and tumor distance from the anal verge influenced local recurrence rates, but only initial tumor stage was associated with long-term survival.

Pathology practice patterns affect lymph node evaluation and outcome of colon cancer: a population-based study

BACKGROUND

A large variation in the number of nodes examined between patients, hospitals, and regions has been reported for patients with colon cancer. We studied determinants of this variation and its relation to survival in the south of The Netherlands.

PATIENTS AND METHODS

All patients who underwent resection for stage I-III colon carcinoma diagnosed from 1999 to 2002 in the Eindhoven Cancer Registry area were included (n = 2168). Determinants of lymph node evaluation and their relationship to survival were assessed, including variation between the six departments of pathology.

RESULTS

A median number of six lymph nodes per specimen had been examined. The median number for each department of pathology ranged from three to eight (P < 0.0001). After correction for relevant factors, this variation remained, resulting in differences in the proportion of N+ tumours between departments from 29% to 41% (P < 0.0001). The number of nodes examined was positively associated with survival. Survival for node-negative patients differed between the departments of pathology (up to hazard ratio 1.5; P = 0.02).

CONCLUSION

There was a large variation in lymph node evaluation between the departments of pathology, leading to differences in stage distribution and survival. Intervention strategies should be directed at nodal assessment.

Evaluation of benign and malignant rectal lesions with CT colonography and endoscopic correlation

Colorectal carcinoma is a significant cause of death from cancer in the United States, and early detection and treatment are critical. Computed tomographic (CT) colonography is a noninvasive, rapidly evolving technique that is a potential alternative to conventional colonoscopy for colorectal cancer screening. Rectal disease (eg, polyps, cancerous lesions, extramucosal lesions, inflammatory disease) can be especially challenging to diagnose with CT colonography because of several factors that can simulate or obscure the disease (eg, over- or underdistention, rectal tube, stool, artifacts). Familiarity with the spectrum of rectal diseases and with the potential pitfalls and technical limitations of CT colonography will help minimize interpretative and perceptual errors.

Increasing negative lymph node count is independently associated with improved long-term survival in stage IIIB and IIIC colon cancer

PURPOSE

The purpose of this study was to examine the impact of the number of negative lymph nodes on survival in patients with stage III colon cancer.

PATIENTS AND METHODS

Patients who underwent surgery for stage III colon cancer between January 1988 and December 1997 were identified from the Surveillance, Epidemiology and End Results cancer registry. The number of negative and positive nodes was determined for 20,702 eligible patients. Disease-specific survival was examined by substage according to the number of negative nodes identified. A proportional hazards model was constructed to determine the effect of the number of negative nodes on survival.

RESULTS

For stage IIIB and IIIC patients, there was a significant decrease in disease-specific mortality as the number of negative nodes increased; cumulative 5-year cancer mortality was 27% in stage IIIB patients with 13 or more negative nodes identified versus 45% in those with three or fewer negative lymph nodes evaluated (P < .0001). In patients with stage IIIC cancer, those with 13 or more negative nodes had a 5-year mortality of 42% versus 65% in those with three or fewer negative lymph nodes evaluated (P < .0001). There was no association between the number of negative nodes identified and disease-specific survival for patients with stage IIIA disease. After controlling for the number of positive nodes, a higher number of negative nodes was found to be independently associated with improved disease-specific survival.

CONCLUSION

The number of negative nodes is an important independent prognostic factor for patients with stage IIIB and IIIC colon cancer.

Laparoscopic colon resection early in the learning curve: what is the appropriate setting?

INTRODUCTION

Laparoscopic colon resection (LCR) is a safe and effective treatment of benign and malignant colonic lesions. There is little question that a steep learning curve exists for surgeons to become skilled and proficient at LCR. Because of this steep learning curve, debate exists regarding the appropriate hospital setting for LCR. We hypothesize that outcomes of LCR performed early in the learning curve at a regional medical center (New Hanover Regional Medical Center; NHRMC) and a university medical center (Baylor College of Medicine; BCM) would not be significantly different.

METHODS

The first 50 consecutive LCRs performed at each institution between August 2001 and December 2003 were reviewed. Age, mean body mass index (BMI), gender, history of previous abdominal surgery (PAS), operative approach [laparoscopic (LAP) versus hand/laparoscopic assisted (HAL)], conversions (Conv), operative time (OR time), pathology (benign vs. malignant), lymph nodes (LN) harvested in malignant cases, length of stay (LOS), morbidity and mortality were obtained. Continuous data were expressed as mean +/- SD. Data were analyzed by chi, Fisher exact test, or t test.

RESULTS

NHRMC patients were on average older females with a higher incidence of PAS. A LAP approach was more frequently performed at BCM (86%), whereas HAL was used more frequently at NHRMC (24%). Conversions to open were similar at both institutions (12%). Benign disease accounted for the majority of operations at both institutions. In cases of malignancy, more LN were harvested at BCM. OR time and LOS were shorter at NHRMC. Complication rates were similar between institutions. There were no anastomotic leaks or deaths.

CONCLUSIONS

LCR can be performed safely and with acceptable outcomes early in the learning curve at regional medical centers and university medical centers. Outcomes depend more on surgeons possessing advanced laparoscopic skills and adhering to accepted oncologic surgical principles in cases of malignancy, than on the size or location of the healthcare institution.

MRI identified prognostic features of tumors in distal sigmoid, rectosigmoid, and upper rectum: treatment with radiotherapy and chemotherapy

PURPOSE

Neoadjuvant therapy is traditionally reserved for locally advanced mid and low rectal cancers. In tumors above this level, the need for adjuvant treatment is based on poor histopathologic features, but this approach has potential disadvantages. The aim of this study was to determine whether magnetic resonance imaging (MRI) could accurately stage tumors of the distal sigmoid, rectosigmoid, and upper rectum and help direct preoperative treatment.

MATERIALS AND METHODS

A total of 75 patients with distal sigmoid, rectosigmoid, and upper rectal tumors were assessed preoperatively by MRI. If tumor extended beyond the planned surgical resection plane, chemoradiotherapy was offered.

RESULTS

Of the 75 patients, 57 (76%) underwent primary surgery. Agreement between the MRI prognosis and histopathologic findings was 84% (95% confidence interval [CI], 72.6-92.7%). The other 18 patients underwent neoadjuvant chemoradiotherapy for poor prognostic features with predicted surgical resection margin involvement. The histopathologic examination confirmed tumor downstaging in 9 of the 18 patients who underwent chemoradiotherapy. The 3-year survival rate in the good prognosis group (91%; 95% CI, 77.1-97.3%) was not significantly different from that of the chemoradiotherapy group (81.4%; 95% CI, 52.4-93.6%). The poor prognosis group undergoing primary surgery had significantly worse survival (62.2%; 95% CI, 30.3-82.8%, p < 0.03).

CONCLUSION

Our findings indicate that tumors of the distal sigmoid, rectosigmoid, and upper rectum can be staged accurately using high spatial resolution MRI and that those with poor prognostic disease may benefit from preoperative therapy.

Is rectal washout necessary in anterior resection for rectal cancer? A prospective clinical study

BACKGROUND

Implantation of exfoliated malignant cells has been suggested as a possible mechanism of tumor recurrence in colorectal anastomoses that might be prevented by cytocidal washout. The aim of our study was to assess whether malignant cells are likely to be collected by a circular stapler introduced transanally to perform an anastomosis and to observe local recurrences during follow-up, with special attention to the washout status of patients.

METHODS

Between May 1999 and March 2004, 96 patients with carcinoma of the rectum and distal sigmoid colon undergoing anterior resection under the care of three surgeons (only one of whom routinely performed rectal washout) were prospectively studied. While 38 patients had rectal washout with 5% povidone-iodine before anastomosis, 58 patients did not. A circular stapler was used for anastomosis, and the stapler was immediately rinsed in 100 ml of saline. The fluid was then classified as "acellular," "malignant cells identified," or "benign cells identified" by pathologists.

RESULTS

Malignant cells were collected from the circular stapler after use in 3 patients (8%) on whom rectal washout was performed and in 2 (3%) patients who did not have rectal washout performed (P=0.631). Three patients (8%) in the washout group developed local recurrence, and 2 patients (3.4%) in the no-washout group had local recurrence (one was anastomotic recurrence) (P=0.338). The median follow-up time was 23 (range: 9-70) months.

CONCLUSIONS

There were no differences in terms of the number of patients who had malignant cells collected from the circular stapler and local recurrence rates between the two groups. Although this is not a randomized study and size and mean follow-up time of the study were not sufficient, our results did not offer rational arguments in support of intraoperative rectal washout when a circular stapler is used after low anterior resection for carcinoma. Because of the limitations of our study, however, we are unable to arrive at a definite conclusion regarding rectal washout. There is a need for a randomized, controlled, large-scale, multicenter trial to establish the clinical relevance of intraoperative rectal washout.

Lymph node retrieval in abdominoperineal surgical specimen is radiation time-dependent

BACKGROUND

A low yield of lymph nodes (LN) in abdominoperineal resection (APR) specimen has been associated with preoperative radiation therapy (XRT) in population-based studies, which may preclude adequate staging of anorectal carcinomas. We hypothesized that the number of LN retrieved in APR specimen was correlated with the dose and the timing of pelvic irradiation.

PATIENTS AND METHODS

We performed a retrospective study of 102 patients who underwent APR in a single institution between 1980 and 2004. Pathological reports were reviewed and the number of lymph nodes retrieved in APR specimens was correlated with: 1) Preoperative radiation; 2) Dose of pelvic irradiation; and 3) Time interval between the end of XRT and surgery.

RESULTS

There were 61 men and 41 women, with a median age of 66 (range 25-89) years. There were 12 patients operated for squamous cell carcinoma of the anal canal (SCCA) and 90 for rectal cancer. 83% and 46% of patients with anal and rectal cancer respectively underwent radical/neoadjuvant radiotherapy. The mean +/- SD number of LN in APR specimen was 9.2 +/- 5.9. The mean number of LN in APR specimen was significantly lower in patients who underwent preoperative XRT (8 +/- 5.5 vs. 10.5 +/- 6.1, Mann-Whitney U test, p = 0.02). The mean number of LN was not significantly different after XRT in patients with SCCA than in patients with rectal cancer (6.2 +/- 5.3 vs. 7.8 +/- 5.3, p = 0.33). Finally, there was an inverse correlation between the yield of LN and the time elapsed between XRT and surgery (linear regression coefficient r = -0.32, p = 0.03).

CONCLUSION

Our data indicate that: 1) radiation therapy affects the yield of LN retrieval in APR specimen; 2) this impact is time-dependent. These findings have important implications with regard to anatomic-pathological staging of anal and rectal cancers and subsequent decision-making regarding adjuvant chemotherapy.

Does rectal cancer shrinkage induced by preoperative radio(chemo)therapy increase the likelihood of anterior resection? A systematic review of randomised trials

BACKGROUND AND PURPOSE

According to common conviction rectal tumour shrinkage after preoperative radio(chemo)therapy increases the likelihood of anterior resection (AR). In order to verify this belief, we performed a systematic review of randomised trials.

PATIENTS AND METHODS

We identified 10 randomised trials encompassing altogether 4596 patients in whom preoperative radio(chemo)therapy resulted in tumour shrinkage in the experimental arm as compared to the control arm.

RESULTS

Tumour shrinkage observed in the experimental groups did not result in a statistically significant higher ARs rate in any study when we performed an analysis of all the randomised cases. Subgroups of patients considered to be candidates for abdominoperineal resection before randomisation were identified in three trials. A statistically significantly higher rate of ARs was demonstrated in the experimental arm of the CAO/ARO/AIO 94 study. However, in that study, sphincter preservation was a secondary endpoint and some features of the trial may bias the estimation of the effect. The benefit of sphincter preservation was not confirmed by subgroup analyses performed in the Lyon R90-01 study and in the Polish study, which were originally designed to evaluate the sphincter preservation issue.

CONCLUSION

The body of evidence gathered from randomised trials does not support the concept of a beneficial effect of preoperative radiotherapy on the ARs rate.

Survival benefit of high ligation of the inferior mesenteric artery in sigmoid colon or rectal cancer surgery

BACKGROUND

The aim of this study was to assess the impact of inferior mesenteric artery (IMA) root nodal dissection before high ligation of the artery on survival in patients with sigmoid colon or rectal cancer.

METHODS

Data on 1188 consecutive patients who underwent resection for sigmoid colon or rectal cancer, with high ligation of the IMA, were identified from a prospective database (April 1965 to December 1999). Survival of patients with involvement of nodes along the IMA proximal to the origin of the left colic artery (root nodes, station 253) through the bifurcation of the superior rectal artery (trunk nodes, station 252) was determined.

RESULTS

Twenty patients (1.7 per cent) had metastatic involvement of station 253 lymph nodes and 99 (8.3 per cent) had metastases to station 252. The 5- and 10-year survival rates of patients with metastases to station 253 were 40 and 21 per cent, and those for patients with metastases to station 252 were 50 and 35 per cent, respectively.

CONCLUSION

High ligation of the IMA allows curative resection and long-term survival in patients with cancer of the sigmoid colon or rectum and nodal metastases at the origin of the IMA.

Adjuvant Chemotherapy with Uracil–Tegafur for Pathological Stage III Rectal Cancer after Mesorectal Excision with Selective Lateral Pelvic Lymphadenectomy: A Multicenter Randomized Controlled Trial*

BACKGROUND

Although adjuvant radiotherapy was proved to be effective for local control of rectal cancer even after standardized mesorectal excision, the role of adjuvant chemotherapy after such standardized surgery remains to be clarified. We aimed to assess the efficacy of a combination of uracil and tegafur for pathological stage III rectal cancer treated by standardized mesorectal excision with selective lateral pelvic lymphadenectomy.

METHODS

We randomly assigned patients with completely resected stage III rectal cancer, who underwent standardized mesorectal excision with selective lateral pelvic lymphadenectomy, to receive either oral uracil-tegafur (400 mg/m2 tegafur per day) for one year or no treatment. Standardization and quality control of the surgery and pathological techniques were ensured by use of the guidelines of the Japanese Society for Cancer of the Colon and Rectum. The primary endpoint was relapse-free survival. The secondary endpoint was overall survival.

RESULTS

We enrolled and randomized 276 patients. Excluding two ineligible patients, 274 were included in the analysis. Planned interim analysis 2 years after accrual termination revealed significant prolongation of relapse-free survival (P = 0.001) and overall survival (P = 0.005) in the uracil-tegafur group. The 3-year relapse-free survival and overall survival rates were 78 and 91% in the chemotherapy group and 60 and 81% in the surgery-alone group, respectively. Local recurrence rates were low in both groups. Grade 3 events occurred in 17% of the chemotherapy patients, but no grade 4 or more events occurred.

CONCLUSION

Adjuvant chemotherapy with uracil-tegafur improves survival of patients with stage III rectal cancer after standardized mesorectal excision with selective lateral pelvic lymphadenectomy.

Lymph node counts, rates of positive lymph nodes, and patient survival for colon cancer surgery in Ontario, Canada: a population-based study

BACKGROUND AND OBJECTIVES

This study assessed lymph node counts, lymph node status (positive or negative), and survival among patients undergoing colon cancer surgery in Ontario, Canada.

METHODS

We obtained data from the Ontario Cancer Registry on 960 patients who underwent a major colon cancer resection in years 1991-1993. Patients and hospitals were ranked by lymph node count to correlate lymph node counts and lymph node status. For node-negative patients we assessed the influence of patient, hospital, and tumor factors on lymph node counts and survival.

RESULTS

The rate of node-positive patients was similar among the lymph node count groups. For example, the odds ratio of a patient being node positive if the lymph node count was 10-36 versus 1-3 was 1.0 (CI 0.6-1.6, P = 0.42). Among node-negative patients, survival was improved for patients with a high (10-36) versus low (1-3) lymph node count (HR 0.6, CI 0.4-1.0, P = 0.03). No patient, hospital, or tumor factors predicted both a higher lymph node count and improved survival.

CONCLUSIONS

In this population-based study of patients undergoing colon cancer surgery, higher lymph node counts did not correlate with increased rates of node-positive status.

Number of Lymph Node Metastases Is Better Predictor of Prognosis Than Level of Lymph Node Metastasis in Patients with Node-Positive Colon Cancer

BACKGROUND

Lymph node metastasis is the most important prognostic factor for colon cancer patients. Survival is also related to the number and level of positive lymph nodes (PLNs). Definitions of degree of PLNs for colon cancer differ greatly between the number and level of PLNs.

STUDY DESIGN

The aim of this study is to compare number and level of PLNs to see which is a better predictor of prognosis for node-positive colon cancer. One hundred eighteen patients underwent histologically curative resection for node-positive colon cancer. We calculated the cumulative 5-year survival rates and examined prognostic factors for multivariate analysis based on the number and level of PLNs and additional factors. The number of PLNs was classified as either one to three PLNs or more than four PLNs, and level of PLNs was classified as either Level I (pericolic lymph node metastasis) or Level II (lymph node metastasis along the major named vessel supplying the tumor, and that around the origin of a main artery).

RESULTS

Cumulative 5-year survival rates were statistically different between the 1 to 3 PLNs group and the more than 4 PLNs group, but not significantly different between Level I group and Level II group. Multivariate analysis showed that number, not level, of PLNs was an independent prognostic factor.

CONCLUSIONS

In node-positive colon cancer, number of PLNs predicted prognosis better than level of PLNs.

Staging and prognosis of colon cancer

Significant advances have been made in all aspects of care relating to colorectal cancer. Although surgery will likely remain the mainstay of definitive treatment for the majority of colorectal malignancies, a better understanding of tumor progression and biology will help guide the choice of surgical therapy to best achieve a curative resection. Additionally, advances in the use of neoadjuvant and adjuvant therapies should continue to increase disease-free and overall survival when combined with appropriate operative resection. Although TNM staging remains our strongest tool at this point for establishing prognosis and directing therapy, expansion of our knowledge of the molecular events underlying colorectal tumorigenesis undoubtedly will lead to the refinement of our current staging and prognostic systems.

Surgical treatment of rectal cancer: radical resection

Currently, surgery is the only potentially curative treatment modality for rectal cancer. The major goals of surgery for rectal cancer are to optimize oncologic outcome and maintain anorectal and genitourinary function. This article reviews the surgical management of primary rectal cancer and discusses major surgical considerations in the treatment of this disease.

Distal intramural spread of rectal cancer after preoperative radiotherapy: the results of a multicenter randomized clinical study

PURPOSE

To evaluate the extent of distal intramural spread (DIS) after preoperative radiotherapy for rectal cancer.

METHODS AND MATERIALS

A total of 316 patients with T(3-4) primary resectable rectal cancer were randomized to receive either preoperative 5x5 Gy radiation with immediate surgery or chemoradiation (50.4 Gy, 1.8 Gy per fraction plus boluses of 5-fluorouracil and leucovorin) with delayed surgery. The slides of the 106 patients who received short-course radiation and of the 86 who received chemoradiation were available for central microscopic evaluation of DIS.

RESULTS

The length of DIS did not differ significantly (p = 0.64) between the short-course group and the chemoradiation group and was 0 in 47% vs. 49%; 1 to 5 mm in 41% vs. 42%; 6 to 10 mm in 8% vs. 9%, and greater than 10 mm in 4% vs. 0, respectively. Among the 11 clinically complete responders, DIS was found 1 to 5 mm from the microscopically detected ulceration of the mucosa in 5 patients. The discontinuous DIS was more frequent in the chemoradiation group as compared with the short-course group (i.e., 57% vs. 16% of cases, p < 0.001).

CONCLUSIONS

Approximately 1 out of 10 advanced rectal cancers after preoperative radiotherapy or radiochemotherapy was characterized by DIS of over 5 mm. No significant difference was seen in the length of DIS between the 2 groups.

Combined resection of the duodenum and pancreas for locally advanced colon cancer

Colorectal cancer invading adjacent organs is a frequent event occurring in 5.5% to 12% of all colorectal malignancies. Colon cancer directly invading the duodenum and pancreas is rare and may require combined resection of the colon, pancreas, and duodenum, which represents a complex operation with significant morbidity and mortality rates. In this article, a case of a 41-year-old patient with a right colon cancer directly infiltrating the duodenum and head of the pancreas is presented. The patient was treated by radical combined resection of the colon, duodenum, and pancreas. Pathological examination confirmed neoplastic invasion of the adjacent organs and absence of lymph node metastasis (T4N0). The patient recovered uneventfully. Patients with colorectal cancer infiltrating adjacent organs such as the duodenum and the pancreas should be treated by radical en bloc resection of the tumor. This procedure is the preferred treatment strategy because it seems to be associated with improved overall survival rates.

Prognostic value of tumour regression grading and depth of neoplastic infiltration within the perirectal fat after combined neoadjuvant chemo-radiotherapy and surgery for rectal cancer

OBJECTIVE

To evaluate histological variables correlated with pathological response to chemo-radiotherapy protocols for rectal cancer and with local recurrence and survival.

METHODS

From 1994 to 2003, 58 patients with rectal cancer were enrolled in a non-randomised study based on standardised treatment with radiotherapy, 5-fluorouracil, and surgical resection, followed by histological examination, including tumour regression grading and depth of neoplastic infiltration within the perirectal fat. All patients were followed up. Mean (SD) length of follow up was 55.3 (28.1) months, range 5 to 108.

RESULTS

No case was found with no regression (grade 0). Tumour regression was defined as grade 1 in 24.5% of cases, grade 2 in 58.5%, grade 3 in 7.5%, and grade 4 (complete regression) in 9.5%. Neoplastic infiltration of >4 mm within the perirectal fat was found in 25.6% of cases in grade 1, 55.8% in grade, 2.7% in grade 3, and 11.6% in grade 4. In 80% cases of pT4 depth of neoplastic infiltration within the perirectal fat was >4 mm (100% were pN+), and the same spread was also found in 53.4% of pT2 and 86.2% of pT3. Pathological response was associated with regression grade (p = 0.006) and depth of neoplastic infiltration within the perirectal fat (p = 0.04). Tumour regression grading was an independent variable for pT (p = 0.0002), pN status (p = 0.00004), pathological staging (p = 0.000001), and local recurrence (p = 0.003).

CONCLUSIONS

Involvement of the lateral resection margins correlates with a poor prognosis and indicates the likelihood of local recurrence of rectal cancer. Tumour regression grading and the depth of neoplastic infiltration within the perirectal fat are important prognostic factors that need to be evaluated routinely.

Prognostic relevance of occult tumour cells in lymph nodes in colorectal cancer

AIMS

Presently, in Europe the treatment of node-negative colorectal cancer (CRC) patients consists of surgical resection of the primary tumour without adjuvant systemic therapy. However, up to 30% of these patients will develop disease recurrence. These high-risk patients are possibly identified by occult tumour cell (OTC) assessment in lymph nodes. In this paper, studies on the clinical relevance of OTC in lymph nodes are reviewed.

METHODS

A literature search was conducted in the National Library of Medicine by using the keywords colonic, rectal, colorectal, neoplasm, adenocarcinoma, cancer, lymph node, polymerase chain reaction, mRNA, immunohistochemistry, micrometastases and isolated tumour cells. Additional articles were identified by cross-referencing from papers retrieved in the initial search.

RESULTS

The upstaging percentages through OTC assessment and the prognostic relevance of OTC in lymph nodes vary among studies, which is related to differences in techniques used to detect OTC.

CONCLUSIONS

We conclude that OTC examination techniques should be standardized to illuminate whether OTC in lymph nodes can reliably identify high-risk node-negative patients.

Surgical Treatment of Colon Cancer

Over 100,000 Americans are diagnosed each year with colon cancer and approximately 90% are treated surgically. Most undergo a curative intent resection, but 30 to 50 percent will have a recurrence of their disease. While much of the variability in outcomes depends on the stage of the disease and other tumor variables, it is now clear that surgeon variables such as caseload and training affect both local recurrence and patient survival. Operative techniques including laparoscopic and other minimally invasive procedures and surgical decisions including choice of operative procedure, management of cancer arising in polyps and treatment of metastatic disease affect outcomes. The role of postoperative surveillance for recurrence remains controversial.

Hypermethylation of the TPEF/HPP1 gene in primary and metastatic colorectal cancers

The role of promoter methylation in the process of cancer cell metastasis has, however, not yet been studied. Recently, methylation of the TPEF (transmembrane protein containing epidermal growth factor and follistatin domain) gene was reported in human colon, gastric, and bladder cancer cells. Using the Methylight assay, TPEF/HPP1 gene methylation was assessed in primary colorectal cancers (n = 47), matched normal colon mucosa, as well as in the liver metastasis of 24 patients with colorectal cancer, and compared to the methylation status of the TIMP-3, APC, DAPK, caveolin-2, and p16 genes. TPEF was frequently methylated in primary colorectal cancers (36 of 47) compared to the normal colon mucosa (1 of 21) (P < .0001), and TPEF mRNA expression in colon cancer cell lines was restored after treatment with 5-aza-2'-deoxycytidine. The p16 and APC genes were also frequently methylated in primary colorectal cancers (P < .02) compared to the normal colon mucosa. Interestingly, promoter methylation was significantly more frequent in proximal, nonrectal cancers (P < .05). Furthermore, a high degree of methylation of the TPEF gene was also observed in liver metastasis (19 of 24). In summary, we observed frequent TPEF methylation in primary colorectal cancers and liver metastases, indicating that epigenetic alterations are not only present in the early phases of carcinogenesis, but are also common in metastatic lesions. The high frequency of TPEF methylation in this series of colorectal cancers underscores the importance of epigenetic changes as targets for the development of molecular tests for cancer diagnosis.

Recidiva local en el cáncer de colon y recto

Data on the incidence of colorectal cancer are alarming and reveal that it is currently the second cause of death from cancer. Most of these deaths are due to recurrence after surgery with curative intent. The factors associated with locoregional recurrence are mainly related to the tumor's histopathological characteristics and grade of invasion. With adequate training the surgeon should not appear among these factors. In rectal cancer this training involves the technique of mesorectal excision, adequate circumferential margin and selective neoadjuvant chemoradiotherapy. After curative resection, patients should be followed-up to detect asymptomatic recurrence. Isolated local recurrence occurs in 20-30% of patients, but even with liver or lung metastases curative surgery can be attempted and success depends on correct multidisciplinary preoperative evaluation. If the diagnosis is made when the tumor is in an incurable phase, the aim is to improve the patient's quality of life.

Total mesorectal excision for rectal cancer: difference in outcome for low and high rectal cancer

PURPOSE

This prospective study was designed to assess the outcome through the first five years after the introduction of total mesorectal excision in 1993 in a Norwegian central hospital, with special regard to the difference between low (< or =6 cm from anal verge) and high (>6 cm) rectal cancers.

METHODS

A total of 140 patients (81 males; median age, 64 (range, 29-87) years) underwent surgery for rectal cancer under curative intention.

RESULTS

Local recurrence rates were 8 of 44 (18 percent) for the low cancers and 5 of 96 (5 percent) for the high, a statistically significant difference (P = 0.0014). Corresponding numbers when the R1 resections are excluded were 5 of 36 (13 percent) for the low and 4 of 92 (4 percent) for the high cancers (P = 0.002). The five-year survival after R0 resections of cancers <6 cm was significantly reduced compared with those >6 cm. The five-year overall survival for the whole material was 72 percent.

CONCLUSIONS

Surgery alone for rectal cancer can achieve overall good results, with five-year overall survival of 72 percent. The prognosis of the cancers of the lower rectum seems to be inherently different from the tumors of the higher level, both concerning local recurrence and five-year survival, suggesting different biologic behavior of the two cancers.

Optimal ligation level of the primary feeding artery and bowel resection margin in colon cancer surgery: the influence of the site of the primary feeding artery

PURPOSE

In colon cancer surgery, it is recommended that en bloc resection involving extended lymphadenectomy, characterized as a hemicolectomy, be performed by ligating the primary feeding artery at a high position and resecting proximal and distal with 5-cm to 10-cm bowel margins. However, there is little evidence to unequivocally support such extensive lymphovascular resection.

METHODS

The distribution of nodal metastases was obtained by the clearing method in 164 patients with colon cancer.

RESULTS

For pericolic spread, for pT1 tumors, the distance from the primary tumor to a diseased node was 2.5 cm; for pT2, the distance was less than 5 cm; for 97.0 percent of pT3 tumors and 93.3 percent of pT4 tumors with nodes involved, the distance was less than 7 cm. For central spread, for pT1 tumors, the rate of spread to central nodes was 0 percent; for pT2, the rate of spread was 20.0 percent to intermediate nodes (for tumors more than 5 cm from the feeding artery, the rate for central nodes was 0 percent); for pT3, the rate was 30.6 percent to intermediate nodes and 15.3 percent to main nodes; for pT4, the rate was 44.4 percent to intermediate nodes and 22.2 percent to main nodes. For curative resection cases with pT3 tumors more than 7 cm from the feeding artery, the rate to central nodes was 0 percent.

CONCLUSIONS

In T1 tumors, central node dissection is not required, but resection with proximal and distal 3-cm margins are required; in T2, central node dissection that includes the intermediate node should be performed in addition to resection with proximal and distal 5-cm margins. In T3 and T4, central node dissection that includes the main node should be performed in addition to resection with proximal and distal 7-cm margins. However, for T2 more than 5 cm from the primary feeding artery, and for T3 more than 7 cm from the primary feeding artery, proximal and distal resection alone may be adequate.

Prognostic and predictive value of the thymidylate synthase expression in patients with non-metastatic colorectal cancer

AIMS

To assess the value of thymidylate synthase (TS) expression as a predictive factor in the efficacy of adjuvant chemotherapy in colorectal cancer, as well as its independent prognostic value for survival.

METHODS

We studied 114 high risk colorectal carcinoma patients (high risk stage II and stage III), distributed in two treatment groups: surgery alone (61 patients) or surgery followed by 5-FU-based chemotherapy (53 patients). TS protein expression in the tumour tissue was assessed by immunohistochemistry.

RESULTS

In the surgery alone subgroup, overall survival (OS) at 5 years were 77.5% for the patients with low TS expression, against 57.7% for the patients with high TS expression (p=0.006). Among patients with low TS, there was no difference in OS as a result of whether adjuvant chemotherapy was carried out or not (65.8 vs 77.5%, p=0.29). Among the patients with high TS, there was a significant gain in OS in favor of chemotherapy (87.8 vs 57.7%, p=0.04). Analyzing the complete sample, TS expression was not shown as an independent prognostic factor for survival in the multivariate analysis.

CONCLUSIONS

The immunohistochemical TS expression may be used for selecting patients for better adjuvant chemotherapy protocols. In this sample, TS expression was not an independent prognostic factor for survival.

T4 Rectal Cancer: Analysis of Patient Outcome after Surgical Excision

Locally advanced rectal cancer dictates a major surgical undertaking, which includes en bloc resection of the rectum and all involved organs. The aim of this study was to evaluate patient outcome and compare multimodality treatment options after various surgical approaches from one institution for T4 rectal cancer. A retrospective chart review identified 24 patients who were operated on for advanced primary rectal cancer invading adjacent structures (T4) over a 5½-year period. The types of treatment and outcome were analyzed. From these 24 patients, the most frequently involved organ was the bladder (33%). A total of 16 patients underwent chemoradiotherapy. There were 12 complications (50%), the most common being wound infection (33% of complications, 17% overall). Nine patients had nodal disease. Disease-free survival was 54 per cent, and overall survival was 75 per cent. However, disease-free survival in node-negative patients was 67 per cent versus 33 per cent in node-positive individuals. Out of the six patients who died in this review, five (83%) received chemoradiotherapy. Operations for advanced primary rectal cancer with involvement of adjacent organs are major procedures associated with high morbidity. Patients without nodal disease may have long-term survival despite the locally advanced tumor. Interestingly, neoadjuvant therapy, adjuvant, or both, did not increase survival.