Impact of surgical and pathologic variables in rectal cancer: a United States community and cooperative group report

Influence of caseload and surgical speciality on outcome following surgery for colorectal cancer: a review of evidence. Part 2: long-term outcome

OBJECTIVE

We reviewed recent literature to assess the impact of hospital caseload, surgeon's caseload and education on long-term outcome following colorectal cancer surgery.

METHOD

We searched the MEDLINE and Cochrane Library databases for relevant literature starting from 1992. We selected hospital caseload, surgeon's caseload and surgeon's education, type of hospital, and surgeon's experience as variables of interest. Measures of outcome were recurrence-free survival and overall survival, and for rectal cancer frequency of permanent stoma. We reviewed the 34 studies according to tumour location: colonic cancer, rectal cancer, or colorectal cancer. We described the studies individually and performed a meta-analysis whenever it was considered appropriate.

RESULTS

For colonic cancer, overall survival improved with increasing hospital caseload, odds ratio (OR) 1.22 [95% confidence interval (CI) 1.16-1.28], and surgeon's education. For rectal cancer, overall survival improved with increasing hospital caseload, OR 1.38 (95% CI 1.19-1.60), and, possibly by surgeon' education and experience. Cancer-free survival was strongly influenced by surgeon's education. The colostomy rate was less in high caseload hospitals, OR 0.76 (95% CI 0.68-0.85). For colorectal cancer, overall survival improved with surgeon's education.

CONCLUSION

The data have provided evidence that long-term survival following colorectal cancer surgery in general improved significantly with increasing hospital caseload and surgeon's education.

The clinical significance of the circumferential resection margin following preoperative pelvic chemo-radiotherapy in rectal cancer: why we need a common language

OBJECTIVE

The presence of microscopic tumour cells within 1 mm of the circumferential surgical resection margin (CRM) is the endpoint most strongly associated with local recurrence in rectal cancer and doubles the risk of developing distant metastases. Reporting on the CRM can monitor surgical quality assurance and over the past two decades has driven advances in surgical technique with the increasing use of total mesorectal excision. The aim of this review was to use the evidence from both phase II and phase III randomized trials of preoperative radiotherapy and chemoradiation in rectal cancer, to assess how often CRM involvement is currently documented and examine its utility as an early predictor of both disease-free and overall survival.

METHOD

A literature search identified both randomized and nonrandomized trials of preoperative radiation therapy and chemoradiation therapy in rectal cancer since 1993. The aim was to find those studies, which documented the distance from the periphery of the tumour and the CRM. Small trials treating < 20 patients were excluded.

RESULTS

One hundred and eighty-seven phase II and 28 phase III trials of preoperative radiotherapy or chemoradiation were identified. Most trials documented the degree of response but only 10 of 187 phase II/retrospective studies and four of 28 phase III trials presented data on the achievement of a negative CRM. Few defined this early pathological endpoint prospectively with accurate measurements. However, the majority of studies did use the definition of <or= 1 mm as an involved CRM. Discussion Pathological parameters have been used as early endpoints to compare studies of preoperative radiotherapy or chemoradiation. It remains uncertain whether the degree of response to chemoradiation (e.g. complete pathological response, downsizing the primary tumour, sterilizing the regional nodes, tumour regression grades or residual cell density) or the achievement of a curative resection (uninvolved CRM) is the best early clinical endpoint. Retrospective studies in rectal cancer have confirmed a strong association between the presence of microscopic tumour cells within 1 mm of the CRM and increased risks of both local recurrence and distant metastases. However, as yet this early pathological endpoint lacks structured measurement and analysis techniques to control for intra- and inter-observer variation and has not been validated as a potential surrogate for local control and survival. Recommendations are made as to the most appropriate information, which should be documented in future trials.

CONCLUSION

The CRM status predicts outcome after surgery alone, preoperative radiotherapy and preoperative chemoradiation. Yet CRM status and its measurement has been poorly documented in the literature, and rarely as a prospective measure of outcome. The CRM should be measured and documented in all cases, using the definition of <or= 1 mm to denote an involved CRM. This definition should also be incorporated into future rectal cancer studies with the use of a standardized proforma.

Learning curve for total gastrectomy with D2 lymph node dissection: cumulative sum analysis for qualified surgery

BACKGROUND

This study was conducted to evaluate the leaning curve of D2 lymph node dissection for patients with gastric cancer in a high-volume center.

METHODS

The authors prospectively reviewed the data of all patients who underwent total gastrectomy with D2 lymph node dissection during a 4-year period. Retrieved lymph node number was used as a surrogate marker of oncological outcome. The retrieved lymph node number cut-off value required for satisfactory D2 lymph node dissection was defined as >25. Cumulative sum analysis was used to examine the learning curves of individual surgeons at target accuracy rates of 85%, 90%, 92.5%, 95%, and 98%.

RESULTS

Two junior staff surgeons performed 198 curative-intent total gastrectomies with D2 lymph node dissections during the study period; their success rates exceeded 90%. Operating time decreased with operative experience (Pearson correlation coefficient = -0.515, P < 0.001). The learning period for total gastrectomy with D2 lymph node dissection for these two junior members of staff was calculated as 23-35 cases, presuming a 92.5% success rate.

CONCLUSIONS

The current study suggests that the surgical learning period for D2 lymph node dissection extends to at least 23 cases or 8 months. In clinical trials containing gastric cancer surgery, the learning curve for qualified surgery from the standpoint of oncological outcome should be considered to minimize bias due to surgeon-associated factors.

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.

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.

Histological examination of circular stapled ‘doughnuts’: Questionable routine practice?

BACKGROUND

Left-sided colonic resections are often anastomosed by the use of the circular stapling gun. Most surgeons routinely submit the resulting set of 'doughnuts' for histological examination.

AIM

The aim of this study is to question the need for this practice by providing our own experience of the impact of 'doughnut' submission on patient management.

PATIENTS AND METHODS

Patients who had undergone a stapled anastomosis for colorectal cancer resection (1998-2004) were identified from the department cancer database and clinical records and histopathological reports were reviewed for all cases.

RESULTS

From a consecutive series of 100 sets of doughnuts only two showed histological abnormality (inflammatory change and a metaplastic polyp). Three patients had local recurrence over the follow-up period: 12, 14 and 36 months after surgery. Histological review of the 'doughnuts' in these patients did not show any abnormality. None of the above findings had any influence on subsequent management.

CONCLUSION

Histological examination of the 'doughnuts' has a considerable impact in terms of time and resource use. This study has shown no benefit in performing routine histological examination of the 'doughnuts'.

Key issues in reporting common cancer specimens: problems in pathologic staging of colon cancer

CONTEXT

Standardized pathologic assessment is a quality measure for cancer care.

OBJECTIVE

Pathologic staging parameters and the clinically important stage-independent pathologic factors that pathologists find most problematic to evaluate in colorectal cancer resection specimens are reviewed. The objective of this review is to provide practical guidance for the practicing surgical pathologist.

DATA SOURCES

Published literature related to the TNM staging system for colorectal cancer of the American Joint Committee on Cancer and the International Union Against Cancer and to stage-independent tissue-based prognostic factor evaluation was included in the review. STUDY SELECTION, DATA EXTRACTION, AND SYNTHESIS: Published guidelines from authoritative sources and published peer-reviewed data related to colorectal cancer staging and pathologic prognostic factor assessment were included for consideration. The general and site-specific rules of application of the American Joint Committee on Cancer and International Union Against Cancer TNM staging system for the colorectum and the protocol for evaluation of colorectal cancer resection specimens of the Cancer Committee of the College of American Pathologists served as the basis for discussion and amplified with practical advice on specific application.

CONCLUSIONS

Standardization of pathologic evaluation of colorectal cancer resection specimens is essential for optimal patient care and is aided by the use of data-driven guidelines that are easily understood and consistently applied.

Anemia and long-term outcome in adjuvant and neoadjuvant radiochemotherapy of stage II and III rectal adenocarcinoma: The Freiburg experience (1989-2002)

AIM: To evaluate the long-term outcome of standard 5-FU based adjuvant or neoadjuvant radiochemotherapy and to identify the predictive factors, especially anemia before and after radiotherapy as well as hemoglobin increase or decrease during radiotherapy.

METHODS: Two hundred and eighty-six patients with Union International Contre Cancer (UICC) stage II and III rectal adenocarcinomas, who underwent resection by conventional surgical techniques (low anterior or abdominoperineal resection), received either postoperative (n = 233) or preoperative (n = 53) radiochemotherapy from January 1989 until July 2002. Overall survival (OAS), cancer-specific survival (CSS), disease-free survival (DFS), local-relapse-free (LRS) and distant-relapse-free survival (DRS) were evaluated using Kaplan-Meier, Log-rank test and Cox’s proportional hazards as statistical methods. Multivariate analysis was used to identify prognostic factors. Median follow-up time was 8 years.

RESULTS: Anemia before radiochemotherapy was an independent prognostic factor for improved DFS (risk ratio 0.76, P = 0.04) as well as stage, grading, R status (free radial margins), type of surgery, carcinoembryonic antigen (CEA) levels, and gender. The univariate analysis revealed that anemia was associated with impaired LRS (better local control) but with improved DFS. In contrast, hemoglobin decrease during radiotherapy was an independent risk factor for DFS (risk ratio 1.97, P = 0.04). During radiotherapy, only 30.8% of R0-resected patients suffered from hemoglobin decrease compared to 55.6% if R1/2 resection was performed (P = 0.04). The 5-year OAS, CSS, DFS, LRS and DRS were 47.0%, 60.0%, 41.4%, 67.2%, and 84.3%, respectively. Significant differences between preoperative and postoperative radiochemotherapy were not found.

CONCLUSION: Anemia before radiochemotherapy and hemoglobin decrease during radiotherapy have no predictive value for the outcome of rectal cancer. Stage, grading, R status (free radial margins), type of surgery, CEA levels, and gender have predictive value for the outcome of rectal cancer.

MRI directed multidisciplinary team preoperative treatment strategy: the way to eliminate positive circumferential margins?

Histopathological audit of positive circumferential resection margins (CRMs) can be used as a surrogate measure of the success of rectal cancer treatment. We audited CRM involvement in rectal cancer patients and the impact of the multidisciplinary team (MDT) on implementing a magnetic resonance imaging (MRI)-based preoperative treatment strategy. Data were collected on all newly diagnosed rectal cancer patients treated in our network between January 1999 and December 2002. Data were analysed for MRI prediction and histopathological assessment of CRM together with the MDT meeting treatment decisions. The CRM+ve rate of those discussed at MDT vs those not discussed were compared. We re-audited the CRM+ve rates 1 year after introducing a policy of mandatory preoperative MRI-based MDT discussion. Of the 298 patients diagnosed with rectal cancer, 39 (13%) were deemed palliative, 178 underwent surgery alone and 81 underwent neoadjuvant therapy. Of these, 62 out of 178 patients underwent surgery alone without MRI-based MDT discussion resulting in positive CRM in 16 cases (26%) as compared to 1 out of 116 (1%) in those patients with MDT discussion of MRI. Overall CRM+ve rate in all nonpalliative patients with or without MDT discussion was 12.5% (32 out of 256), significantly lower than the <20% rate (P<0.001) quoted in national guidelines. Re-audit in 98 consecutive patients following a change of policy produced a lower CRM+ve rate of 3% (1 out of 37) for all surgery alone patients and an overall CRM+ve rate of 7% (5 out of 70). In conclusion, MDT discussion of MRI and implementation of a preoperative treatment strategy results in significantly reduced positive CRM in rectal cancer patients.

The influence of the surgeon’s and the hospital’s caseload on survival and local recurrence after colorectal cancer surgery

BACKGROUND

Past studies have identified surgeon- and institution- related characteristics as prognostic factors in colorectal cancer surgery. The present work assesses the influence of the surgeon's and the hospital's caseload on long-term results of colorectal cancer surgery.

METHODS

The data on 2706 patients from 2, randomized, colorectal cancer trials (Swiss Group for Clinical Cancer Research [SAKK] 40/81, SAKK 40/87) investigating adjuvant intraportal and systemic chemotherapy and 1 concurrent registration study (SAKK 40/88) were reviewed. A first analysis included 1809 eligible, nonmetastatic patients from all 3 studies. A subsequent subgroup analysis included 915 eligible patients from both randomized trials. Overall survival (OS), disease-free survival (DFS), and local recurrence (LR) were analyzed in multivariate models taking into account the possible effect of clustering. The main potential covariates were surgeon's annual caseload (>5 operations/year vs < or =5 operations/year), hospital's annual caseload (>26 operations/year vs < or =26 operations/year), tumor site, T stage, and nodal status.

RESULTS

Primary analysis of all 3 studies combined found a high surgeon's caseload to be positively associated with OS (P = .025) and marginally with DFS (P = .058). Separate analysis for each trial, however, showed that a high surgeon's caseload was beneficial for outcome in both randomized trials but not in the registration study. A subgroup analysis of 915 patients with 376 rectal and 539 colonic primaries from both randomized trials, therefore, was performed. Neither age, gender, year of operation, adjuvant chemotherapy (intraportal vs systemic vs operation alone), hospital academic status (university vs non-university), training status of the surgeon (certified surgeon vs surgeon-in-training), nor inclusion in 1 of the 2 randomized trials (SAKK 40/81 vs SAKK 40/87) was a significant predictor of outcome. However, both high surgeon's and high hospital's annual caseloads were independent, beneficial prognostic factors for OS (P = .0003, P = .044) and DFS (P = .0008, P = .020), and marginally significant factors for LR (P = .057, P = .055).

CONCLUSIONS

High surgeon's and hospital's annual caseloads are strong, independent prognostic factors for extending overall and disease-free survival and reducing the rate of local recurrence in 2 randomized colorectal cancer trials.

Neoadjuvant capecitabine and oxaliplatin followed by synchronous chemoradiation and total mesorectal excision in magnetic resonance imaging-defined poor-risk rectal cancer

PURPOSE

To evaluate neoadjuvant capecitabine/oxaliplatin before chemoradiotherapy (CRT) and total mesorectal excision (TME) in newly diagnosed patients with magnetic resonance imaging (MRI) -defined poor-risk rectal cancer.

PATIENTS AND METHODS

MRI criteria for poor-risk rectal cancer were tumors within 1 mm of mesorectal fascia (ie, circumferential resection margin threatened), T3 tumors at or below levators, tumors extending > or = 5 mm into perirectal fat, T4 tumors, and T1-4N2 tumors. Patients received 12 weeks of neoadjuvant capecitabine/oxaliplatin followed by concomitant capecitabine and radiotherapy. TME was planned 6 weeks after CRT. Postoperatively, patients received another 12 weeks of capecitabine.

RESULTS

Between November 2001 and August 2004, 77 eligible patients were recruited. After neoadjuvant capecitabine/oxaliplatin, the radiologic response rate was 88%. In addition, 86% of patients had symptomatic responses in a median of 32 days (ie, just over one cycle of capecitabine/oxaliplatin). After CRT, the tumor response rate was increased to 97%. Three patients remained inoperable. Sixty-seven patients proceeded to TME, and all but one patient had R0 resection. Pathologic complete response was observed in 16 patients (24%; 95% CI, 14% to 36%), and in an additional 32 patients (48%), only microscopic tumor foci were found on surgical specimens. Four deaths occurred during neoadjuvant capecitabine/oxaliplatin therapy as a result of pulmonary embolism, ischemic heart disease, sudden death with history of chest pain, and neutropenic colitis.

CONCLUSION

Capecitabine/oxaliplatin before synchronous CRT and TME results in substantial tumor regression, rapid symptomatic response, and achievement of R0 resection.

Clinical significance of detection for vascular endothelial growth factor in resection margin following total mesorectal excision

AIM: To investigate the expression and its significance of vascular endothelial growth factor (VEGF) in the resection margin following total mesorectal excision (TME) for human rectal cancer.

METHODS: VEGF was detected in the tissue specimens of cancer, distal mesorectal margin (DMM), circumferential resection margin (CRM) and outer pelvic fascia from 60 rectal cancer patients received TME. The pathological data were retrospectively analyzed.

RESULTS: VEGF expression was significantly higher in the tissues of rectal cancer than that in the normal tissues (54/60 vs2/20, P < 0.001). VEGF was also expressed in tissues of CRM (9/60). However, no VEGF expression was detected in the tissues of DMM and outer pelvic fascia. VEGF expression was closely related with the differentiation degree, Dukes staging and lymph node metastasis (P < 0.05 or P < 0.01).

CONCLUSION: VEGF is highly expressed in tissues of rectal cancer, and negatively or weakly positively expressed in DMM and CRM.

Estándares de calidad de la cirugía del cáncer de recto

The results of surgery for rectal cancer have classically been measured through indicators such as morbidity, mortality, and length of hospital stay. In the last few years other parameters have been included that evaluate healthcare quality such as the functional results of the surgical technique employed and quality of life. Total resection of the mesorectum, performed by experienced surgeons, is the surgical technique of choice. Currently, the sphincter can be preserved in 70% of patients. Anastomotic dehiscence after anterior resection of the rectum is the most serious complication and the most important risk factor is the height of the anastomosis. The overall dehiscence rate should be less than 15% and operative mortality should be between 2% and 3%. The colonic reservoir improves functional outcome and consequently it is the procedure of choice to reconstruct transit after low anterior resection. Local recurrence should be less than 10% and 5-year survival should be between 70% and 80%. In general, quality of life is better after anterior resection of the rectum than after abdominoperineal amputation, despite the functional deterioration presented by some patients.

Education is the key to quality of surgery for rectal cancer

Surgical quality assurance is a central issue in the treatment of rectal cancer and has led to substantial improvements in sphincter preservation, local control, and overall survival. Education or training as well as volume of practice are often cited as the major predictors of quality outcomes. While volume is a simple measure to analyze, it is likely a superficial or surrogate measure of quality surgery. It has been conclusively demonstrated that education, from total mesorectum excision workshops to nation-wide educational initiatives are effective methods of improving quality of care for the rectal cancer patient. New methods of quality assurance and improvement are being developed including prospective quality registers, the synoptic operative report, and pathology audits. It is imperative that improved measures of quality, other than volume, be implemented to audit our own practices, hospitals and regions with the goal of identifying issues that will improve outcomes for rectal cancer patients.

Pathological quality assurance in gastro-intestinal cancer

Quality assurance has become an integrated and important part of surgical pathology. Not only laboratory quality systems and quality control of pathology reporting have been introduced, also interdisciplinary quality systems are being developed. This review focuses on the different aspects of quality assurance that can nowadays be used in the daily practice of pathology management of gastrointestinal cancers, especially, gastric- and colorectal cancer. Own data are, especially, derived from the recently conducted clinical trial on pre-operative radiotherapy for rectal cancer and emphasize the importance of multidisciplinary approaches.

Enhanced tumorocidal effect of chemotherapy with preoperative radiotherapy for rectal cancer: preliminary results--EORTC 22921

PURPOSE

The European Organisation for Research and Treatment of Cancer (EORTC) trial evaluated the addition of chemotherapy (CT) to preoperative radiation (preop RT) and the value of postoperative CT for improving the survival in patients with T3-4 resectable rectal cancer. Patients were allocated to the following four arms: arm 1, preop RT 45 Gy in 5 weeks; arm 2, preop RT plus two 5-day CT courses (fluorouracil 350 mg/m2/d and leucovorin 20 mg/m2/d) in the first and fifth week of RT; arm 3, preop RT plus four postoperative CT courses; and arm 4, preop RT and CT plus postoperative CT. We investigated the effect of adding CT on the pathologic parameters.

PATIENTS AND METHODS

One thousand eleven patients were entered onto the trial; 505 received preop RT (arms 1 and 3), and 506 received preop RT-CT (arms 2 and 4). We analyzed the differences in tumor size, tumor node stage, number of retrieved nodes, and histologic features such as lymphatic, venous, and perineural invasions, tumor differentiation, and tumor type.

RESULTS

After preop RT-CT, tumors were smaller (P < .0001), had less advanced pT (P < .001) and pN stages (P < .001), had small numbers of examined nodes (P = .046), and less frequent LVN invasions (P < or = .008). Mucinous tumors increased after preop RT-CT (P < .001).

CONCLUSION

In patients with rectal cancer, preliminary results of EORTC Trial 22921 indicate that the addition of CT to preop RT induces down-sizing, downstaging, and significant changes in histologic characteristics. Longer follow-up is needed to assess the impact on local control and survival.

The surgeon's expertise-outcome relationship in gastric cancer surgery

PURPOSE

The surgical caseload or duration of practice of a surgeon may influence the outcomes of gastric cancer surgery. This study aimed to clarify the surgical quality provided by specialized gastric cancer surgeons.

MATERIALS AND METHODS

The postoperative courses of 1,877 patients who underwent surgery for gastric cancer were retrospectively reviewed. For classification of the surgeon's expertise, the number of yearly resections performed by, and consecutive years of practice of, the surgeons were used. The outcome measures used were the 30-day mortality and long-term survival.

RESULTS

Surgical mortalities of patients who underwent surgery by a specialized surgeon and those by a general surgeon revealed no statistically significant difference. A significant difference in the five-year survival rates was found with surgeons with at least two consecutive years of practice compared to those with less than two years, when 50 or more cases had been conducted per year (63.9% and 59.7%; p=0.0380). In cases of four-years of consecutive practice, the five-year survival rate was significantly improved, even if only 10 cases were performed annually (64.9% and 58.3%; p=0.0023), although the best survival rate was found with surgeons that had performed 50 or more surgeries per year.

CONCLUSION

Improved survival rates, with acceptable surgical mortality, can be achieved for gastric cancer when the surgery is performed by a specialized surgeon. A specialized gastric cancer surgeon can be defined as one who has operated on more than 50 new cases per year, with 2 or more consecutive years of surgical practice.

Nodal spread and micrometastasis within mesorectum

AIM: To study the distribution of positive lymph nodes within mesorectum and to investigate the possible micrometastasis in negative lymph nodes.

METHODS: Large slice technique combined with tissue microarray was used in the pathologic study of 31 specimens.

RESULTS: A total of 992 lymph nodes were harvested and cancer metastasis was found in 148 lymph nodes. Some positive lymph nodes were located in the outer layer of mesorectum and more at the same site of mesorectum as the primary tumor. Circumferential margin lymph node metastasis was observed in nine cases. No significant difference in occurrence of micrometastasis was observed in different stage tumors.

CONCLUSION: Positive lymph nodes are distributed in mesorectum and micrometastasis can be found in negative lymph nodes.

An Overview of Approaches to Adjuvant Therapy for Colorectal Cancer in the United States

Adjuvant chemotherapy for colon cancer and combined chemotherapy and radiation therapy (RT) for rectal cancer increases the proportion of patients cured of their disease. Adjuvant chemotherapy is indicated for stage III colon cancer, and although controversial for stage II disease, there is evidence to suggest that these patients may benefit as well. Adjuvant chemotherapy and RT is recommended for patients with stage II/III rectal cancer. Studies incorporating oral fluoropyrimidines as well as combination chemotherapy have been completed, with results demonstrating the value of these approaches. A new generation of studies will evaluate the biologic agents bevacizumab and cetuximab in the adjuvant therapy of colorectal cancer. For rectal cancer, optimal outcomes are dependent not only on the systemic therapy, but also on the expertise of the surgeon and the timing of RT, with improved local control and toxicity seen with preoperative therapy.

Impact of preoperative radiation for rectal cancer on subsequent lymph node evaluation: a population-based analysis

PURPOSE

To determine the impact of preoperative radiotherapy (RT) on the accuracy of lymph node staging (LNS). Preoperative RT is a well-established component of rectal cancer treatment but its impact on LNS is unknown.

METHODS AND MATERIALS

The Surveillance, Epidemiology and End Results (SEER) registry, representing 14% of the U.S. population, was used to assess the impact of preoperative RT on LNS. Our study population consisted of adults with rectal cancer between 1998 and 2000 who underwent radical resection.

RESULTS

In our 3-year study period, 5647 patients met the selection criteria and 1034 (19.5%) underwent preoperative RT. The preoperative RT group was younger (average age, 61 years) than those who did not undergo preoperative RT (average age, 69 years) and more likely to be male (22% of men vs. 16% of women). On average, fewer nodes were examined in patients who underwent preoperative RT (7 nodes) vs. those who did not (10 nodes); this difference was statistically significant, controlling for potential confounders (p < or = 0.0001). In 16% of the preoperative RT patients (vs. 7.5% without), no nodes were identified (p < or = 0.0001). If one used a minimum of 12 nodes as the standard, only 20% of patients who underwent preoperative RT underwent adequate LNS.

CONCLUSION

Lymph node staging in patients who undergo preoperative RT must be interpreted with caution. Studies are needed to evaluate the clinical relevance of node number and pathologic staging after preoperative RT for rectal cancer.

The long term survival of rectal cancer patients following abdominoperineal and anterior resection: results of a population-based observational study

AIMS

The surgical management of rectal cancer is not uniform. Both abdominoperineal (APR) and anterior resection (AR) are used in potentially curative surgery but there is no definitive evidence regarding comparative survival outcomes and no randomised controlled trials. We sought to determine if any differences in survival existed between patients who received AR or APR. In addition, we sought to determine how variations in surgical management relate to the degree of specialisation and caseload of the managing consultant.

PATIENTS AND METHODS

A retrospective study of population-based data collected by the Northern and Yorkshire Cancer Registry and Information Service was undertaken. All patients (3521) diagnosed with rectal cancer in the former Yorkshire Regional Health Authority (population 3.6 million) between 1986 and 1994 who received either an APR or AR were included. Survival was assessed in relation to the surgical methods adopted. In addition, we determined whether the extent of specialisation of the managing consultant influenced the type of operation adopted.

RESULTS

A Log Rank test, stratified for sex and age, showed a statistically significant 6.7% 5-year survival advantage for patients receiving AR (p=0.0064). AR was more likely to be performed by more specialist colorectal cancer surgeons (p<0.001).

CONCLUSIONS

This evidence suggests that the outcomes of the two main surgical procedures used in curative surgery for rectal cancer are different and that, when possible, AR should be the operation of choice. Our results show no indication of excess risk associated with this procedure compared with APR.

Ganglions et cancer du rectum

Nodal invasion is a major prognostic factor of rectal cancer. Lymphatic extension of rectal cancer usually involves the mesorectal nodes then the inferior mesenteric chain but in 14% of patients, particularly with cancer of the lower rectum, metastasic nodes can be observed in the internal or lumboaortic chains situated beyond the usual territory of nodal dissection. On average, 30 nodes are examined on a proctectomy specimen, but with wide interindividual variation. The tumor can be adequately staged if at least 15 nodes are examined with little risk of not recognizing nodal metastasis. Metastatic nodes of rectal cancer are almost always small, more than 90% measuring less than 10 mm and 70% less than 5 mm. The number of invaded nodes and the total number of examined nodes are prognostic factors for survival. Hypofrationated preoperative radiotherapy does not alter the nodal status but a long radiotherapy protocol (45 Gy over 5 weeks) reduces significantly the total number of nodes examined without changing the number of metastasic nodes. Micrometastases (measuring less than 2 mm), identified by immunohistochemistry or gene amplification, can be detected in 25 to 70% of nodes considered metastasis-free at the usual microscopic examination. The prognostic value of these micrometastases remains to be established. The first node draining the tumor (sentinel node), which can be detected rapidly with dye infusion, appears to provide a good picture of the nodal status, the risk of finding an invaded node if the sentinel node is metastasis-free is less than 5%.

Learning curve: the surgeon as a prognostic factor in colorectal cancer surgery

The individual surgeon is an independent prognostic factor for outcome in colorectal cancer surgery. The surgeon's learning curve is therefore directly related to the patient's outcome. The exact shape of the learning curve, however, is unknown. The present study reviewed supervision, training/teaching, specialization, surgeon's caseload, and hospital's caseload as the five main surgeon- and hospital-related confounding factors for outcome, and examined their influence on the learning curve as well as their interactions and prognostic significance. All five confounding factors were related to outcome. The highest degree of evidence, however, was found for training/teaching (introduction of total mesorectal excision), specialization in colorectal surgery (special interest, board-certification, specialized colorectal cancer units), and the surgeon's caseload. Five surgeon- and hospital-related factors directly influence the surgeon's learning curve and are therefore rightly considered predictors of outcome in colorectal cancer surgery. Improvements in supervision, training/teaching, specialization, the surgeon's caseload, and the hospital's caseload will therefore translate into enhanced patient outcome.

Sentinel lymph node mapping for adenocarcinoma of the colon does not improve staging accuracy

PURPOSE

This study was designed to: determine the efficacy of sentinel lymph node mapping in patients with intraperitoneal colon cancer; and create an algorithm to predict potential survival benefit by using best-case estimates in favor of sentinel node mapping and lymph node ultraprocessing techniques.

METHODS

Forty-one patients with intraperitoneal colon cancer undergoing colectomy with curative intent were studied prospectively. After mobilization of the colon and mesentery, 1 to 2 ml of isosulfan blue dye was injected subserosally around the tumor. The first several nodes highlighted with blue dye were identified as sentinel nodes. Additional nodes were identified by the pathologist in routine fashion by manual dissection of the mesentery. All nodes were processed in routine fashion by bivalving and hematoxylin and eosin staining. To create an algorithm to predict potential survival benefit of sentinel node mapping and lymph node ultraprocessing techniques, assumptions were made using data from the literature. All bias was directed toward success of the techniques.

RESULTS

Three of 41 patients (7 percent) did not undergo injection of dye and were excluded from further analysis. Stage of disease in the remaining 38 patients was: I, n = 10 (26 percent); II, n = 15 (39 percent); III, n = 11 (29 percent); IV, n = 2 (5 percent). At least one sentinel node was identified in 30 of 38 patients (79 percent). The median number of sentinel nodes identified was two (range, 1-3). Median total nodal retrieval was 14 (range, 7-45). All nodes were negative in 26 of 38 patients (68 percent). Sentinel nodes and nonsentinel nodes were positive in 2 of 38 patients (5 percent). Sentinel nodes were the only positive nodes in 1 of 38 patients (3 percent). Sentinel nodes were negative and nonsentinel nodes were positive in 9 of 38 patients (24 percent). Thus, sentinel node mapping would have potentially benefited only 3 percent, and failed to accurately identify nodal metastases in 24 percent of the patients in our study. To create a survival benefit algorithm, we assumed the following: combined fraction of Stage I and II disease (0.5); fraction understaged by bivalving and hematoxylin and eosin staining that would have occult positive nodes by more sophisticated analysis (0.15); fraction of occult positive nodes detected by sentinel node mapping (0.9); and survival benefit from chemotherapy (0.33). Thus, the fraction of patients benefiting from sentinel lymph node mapping and lymph node ultraprocessing techniques would be 0.02 (2 percent).

CONCLUSIONS

Sentinel node mapping with isosulfan blue dye and routine processing of retrieved nodes does not improve staging accuracy in patients with intraperitoneal colon cancer. Even using best-case assumptions, the percentage of patients who would potentially benefit from sentinel lymph node mapping is small.

Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: long-term results

OBJECTIVE

Report overall long-term results of stage 0 rectal cancer following neoadjuvant chemoradiation and compare long-term results between operative and nonoperative treatment.

METHODS

Two-hundred sixty-five patients with distal rectal adenocarcinoma considered resectable were treated by neoadjuvant chemoradiation (CRT) with 5-FU, Leucovorin and 5040 cGy. Patients with incomplete clinical response were referred to radical surgical resection. Patients with incomplete clinical response treated by surgery resulting in stage p0 were compared to patients with complete clinical response treated by nonoperative treatment. Statistical analysis was performed using chi2, Student t test and Kaplan-Meier curves.

RESULTS

Overall and disease-free 10-year survival rates were 97.7% and 84%. In 71 patients (26.8%) complete clinical response was observed following CRT (Observation group). Twenty-two patients (8.3%) showed incomplete clinical response and pT0N0M0 resected specimens (Resection group). There were no differences between patient's demographics and tumor's characteristics between groups. In the Resection group, 9 definitive colostomies and 7 diverting temporary ileostomies were performed. Mean follow-up was 57.3 months in Observation Group and 48 months in Resection Group. There were 3 systemic recurrences in each group and 2 endorectal recurrences in Observation Group. Two patients in the Resection group died of the disease. Five-year overall and disease-free survival rates were 88% and 83%, respectively, in Resection Group and 100% and 92% in Observation Group.

CONCLUSIONS

Stage 0 rectal cancer disease is associated with excellent long-term results irrespective of treatment strategy. Surgical resection may not lead to improved outcome in this situation and may be associated with high rates of temporary or definitive stoma construction and unnecessary morbidity and mortality rates.

Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: long-term results

OBJECTIVE

Report overall long-term results of stage 0 rectal cancer following neoadjuvant chemoradiation and compare long-term results between operative and nonoperative treatment.

METHODS

Two-hundred sixty-five patients with distal rectal adenocarcinoma considered resectable were treated by neoadjuvant chemoradiation (CRT) with 5-FU, Leucovorin and 5040 cGy. Patients with incomplete clinical response were referred to radical surgical resection. Patients with incomplete clinical response treated by surgery resulting in stage p0 were compared to patients with complete clinical response treated by nonoperative treatment. Statistical analysis was performed using chi2, Student t test and Kaplan-Meier curves.

RESULTS

Overall and disease-free 10-year survival rates were 97.7% and 84%. In 71 patients (26.8%) complete clinical response was observed following CRT (Observation group). Twenty-two patients (8.3%) showed incomplete clinical response and pT0N0M0 resected specimens (Resection group). There were no differences between patient's demographics and tumor's characteristics between groups. In the Resection group, 9 definitive colostomies and 7 diverting temporary ileostomies were performed. Mean follow-up was 57.3 months in Observation Group and 48 months in Resection Group. There were 3 systemic recurrences in each group and 2 endorectal recurrences in Observation Group. Two patients in the Resection group died of the disease. Five-year overall and disease-free survival rates were 88% and 83%, respectively, in Resection Group and 100% and 92% in Observation Group.

CONCLUSIONS

Stage 0 rectal cancer disease is associated with excellent long-term results irrespective of treatment strategy. Surgical resection may not lead to improved outcome in this situation and may be associated with high rates of temporary or definitive stoma construction and unnecessary morbidity and mortality rates.

Evidence supports adjuvant radiotherapy in selected patients with rectal cancer

BACKGROUND

Much recent data have been published on the risk of local recurrence (LR) following curative surgery for rectal cancer and the impact of adjuvant radiation therapy (RT). With improvements in surgical technique apparently reducing the risk of LR, the relevance of older data upon which the current recommendations for adjuvant RT are based has been questioned.

METHODS

A focused review was undertaken of the published literature on the risk of LR following surgery for rectal cancer and the impact of adjuvant radiation. In particular the authors attempt to define how accurately the risk for an individual patient can be predicted, trends in reported LR rates over the time period of randomized trials, and the relevance of changing surgical and RT techniques.

RESULTS

Many of the perceived differences in published results can be explained by variations in study entry criteria, length of follow up and data recording. Comparisons between studies are most accurate when defined subsets of patients, such as those with stage III disease, followed for the same period of time, are considered. In parallel with improvements in surgical technique, which may have reduced the risk of LR, modifications to RT delivery have resulted in recent series not reporting an increased mortality in those patients treated with modern RT techniques.

CONCLUSION

All of the available evidence supports the use of adjuvant RT in selected patients with rectal cancer. Ongoing studies will better define individual patient risk and the risk-benefit ratio of adjuvant RT.

Clinical implications of quantification of mesorectal tumor invasion by endoscopic ultrasound: All T3 rectal cancers are not equal

BACKGROUND

Depth of invasion beyond the muscularis propria (MP) by T3 rectal cancer can vary. The purpose of the present paper was to determine if depth of invasion beyond MP, as assessed by preoperative endoscopic ultrasound (EUS), can predict tumor recurrence in patients with T3 rectal tumors.

METHODS

Patients with T3NxM0 rectal cancer, as determined by EUS, who underwent surgical resection (without preoperative neoadjuvant therapy) were reviewed by two blinded endosonographers. Tumors were classified as minimally invasive T3 (invasion </= 2 mm beyond MP by EUS) and advanced T3 disease (invasion > 2 mm).

RESULTS

Forty-two patients with T3 rectal tumors underwent surgical resection without receiving preoperative neoadjuvant therapy, of whom 14 had minimally invasive T3 and 28 had advanced T3 disease, as determined by preoperative EUS. Median follow up was 19 months. Tumor recurrence rates in minimally invasive and advanced T3 tumors were 14.3% and 39.3%, respectively, P = 0.02 (log-rank test). Adjusting for nodal status and postoperative adjuvant therapy administration, Cox proportional hazards model demonstrated advanced T3 disease (by EUS) to predict tumor recurrence, hazard ratio, 2.28 (95% confidence interval: 1.17-5.81), P = 0.01.

CONCLUSIONS

All T3 rectal tumors are not equal, with minimally invasive disease carrying a more favorable prognosis. By discriminating minimally invasive from advanced T3 disease, preoperative EUS provides important prognostic information. Further subclassification of T3 tumors, based on preoperative EUS staging, should be considered to enhance selection of patients for neoadjuvant therapy.

Extracapsular spread of nodal metastasis as a prognostic factor in rectal cancer

PURPOSE

To evaluate the prognostic value of lymph node metastasis with extracapsular extension (ECE) for local control and metastasis-free survival in rectal cancer.

METHODS AND MATERIALS

A total of 145 rectal cancer patients were treated with surgery and postoperative radiochemotherapy. Patients were grouped according to nodal status (node negative, n = 49; node positive without ECE, n = 64; node positive with ECE, n = 32). In addition, well-known prognostic factors such as International Union Against Cancer (UICC) stage, T and N stage, presence of lymphangiosis, and grade were assessed. The end points were analyzed by the Kaplan-Meier method, and prognostic factors were compared in a Cox regression model.

RESULTS

Of the entire group, the actuarial 5-year local control and distant metastasis-free survival rate was 85% and 66%, respectively, after a median follow-up of 47 months (range, 14-104). Patients with ECE of lymph node metastasis had an impaired 5-year local control rate (58%) compared with node-negative (83%) and node-positive without extracapsular involvement patients (87%, p = 0.041). Metastasis-free survival also differed for the three groups, with a rate of 40% for those with extracapsular involvement, 54% for those without ECE, and 78% for node-negative patients (p <0.0001). The impact of ECE on local control was confirmed in the regression model (risk ratio [RR] 1.6, 95% confidence interval [CI] 1.01-2.7, p = 0.044). T stage was only of borderline significance (RR 2.4, 95% CI 1.0-5.7, p = 0.052). However, only UICC stage (RR 5.1, 95% CI 2.0-13.1, p <0.001) and the presence of lymphangiosis (RR 2.8, 95% CI 1.4-5.3, p = 0.002) were of independent prognostic value for distant metastasis.

CONCLUSION

ECE of node metastasis is connected with a substantial decline in local control. The frequency of distant metastasis is increased in this patient group as well, but stage and lymphangiosis are the independent factors for assessment of a patient's risk of systemic spread.

Outcome of rectal and sigmoid carcinoma patients receiving adjuvant chemoradiotherapy in Marmara University Hospital

Adjuvant chemoradiotherapy is the standard treatment in resected stage II/III rectosigmoid carcinoma. We report a retrospective analysis of 33 patients who received adjuvant chemoradiotherapy. Patients received 5-fluorouracil (375mg/m2/day x 5days) and calcium leucovorin (20mg/m2/day x 5days), q4weeks, two courses before and two courses after radiotherapy. The 5-fluorouracil dose was reduced to 225mg/m2/day given continuously as protracted short-term infusion on the first and last 3 days during radiotherapy. Radiotherapy was started at 7th week and 45-50.4 Gy was given to pelvic region. Median age was 63 years. Median follow-up was 38 months starting from the operation date. Four-year local and distant control rates were 78% and 69%, respectively. Four-year disease-free survival and overall survival were 60% and 62%, respectively. Protracted short-term infusion of 5-fluorouracil during pelvic irradiation is a safe treatment modality. Further studies are needed to improve the local control of high-risk rectal and sigmoid carcinomas.

Impact of Hospital Procedure Volume on Surgical Operation and Long-Term Outcomes in High-Risk Curatively Resected Rectal Cancer: Findings From the Intergroup 0114 Study

Purpose

Prior studies have demonstrated superior outcomes after a curative surgical resection of rectal cancer at hospitals where the volume of such surgeries is high. However, because these studies often lack detailed information on tumor and treatment characteristics as well as cancer recurrence, the true nature of this relation remains uncertain.

Patients and Methods

We studied a nested cohort of 1,330 patients with stage II and stage III rectal cancer participating in a multicenter, adjuvant chemoradiotherapy trial. We analyzed differences in rates of sphincter-preserving operations, overall survival, and cancer recurrence by hospital surgical volume.

Results

We observed a significant difference in the rates of abdominoperineal resections across tertiles of hospital procedure volume (46.3% for patients resected at low-volume, 41.3% at medium-volume, and 31.8% at high-volume hospitals; P < .0001), even after adjustment for tumor distance from the anal verge. However, this higher rate of sphincter-sparing operations at high-volume centers was not accompanied by any increase in recurrence rates. Hospital surgical volume did not predict overall, disease-free, recurrence-free, or local recurrence-free survival. However, among patients who did not complete the planned adjuvant chemoradiotherapy (270 patients), those who underwent surgery at low-volume hospitals had a significant increase in cancer recurrence (adjusted hazard ratio, 1.94; 95% CI, 1.01 to 3.72; P = .04 for the trend) and a nonsignificant trend toward increased overall mortality (P = .08) and local recurrence (P = .10). In contrast, no significant volume-outcome relation was noted among patients who did complete postoperative therapy.

Conclusion

Using prospectively recorded data, we found that hospital surgical volume had no significant effect on rectal cancer recurrence or survival when patients completed standard adjuvant therapy. Sphincter-preserving surgery was more commonly performed at high-volume centers.

Surgical pathology for the oncology patient in the age of standardization: of margins, micrometastasis, and molecular markers

From initial diagnosis through definitive treatment, pathologic evaluation plays a central role in the care of patients with cancer. All patient management is dependent on the correct tissue diagnosis. For surgically resected malignancies, the pathologic stage is widely recognized as the most accurate predictor of survival, and it typically determines the appropriateness of adjuvant treatment as well. Numerous additional pathologic factors have been shown by multivariate analyses to have prognostic significance that is independent of stage, and these may help to further substratify tumors, individualize treatment, and more accurately predict outcome. On a larger scale, pathologic data are essential for epidemiologic and clinical research and is the common language of cancer worldwide. Despite its overriding importance, however, current pathologic analysis is fraught with variations in methodology, interpretation of findings, terminology, reporting norms, and statistical approaches that compromise its utility, both to the individual patient and to the progress of cancer medicine and research. In the last 5 years, increasing attention has been focused on the negative impact of variation in pathology practices on patient care and medical progress at all levels including institutional, regional, national, and international. This problem is within the immediate ability of the pathology profession to correct, and the author's prediction for oncologic pathology over the next 5 years is that standardization based on best practices will become, itself, the standard.

New developments in therapy for colorectal cancer

Colorectal cancer remains a significant cause of cancer death, and its treatment is the subject of active, ongoing investigation within all treatment modalities, including surgery, chemotherapy, and radiotherapy. In this review we discuss selected interesting and important research findings since the year 2000 and comment on their potential impact on the adjuvant and advanced disease management of patients with colon and rectal cancer.

Overview of preoperative and postoperative therapy for colorectal cancer: the European and United States perspectives

Surgery is the primary modality for cure in patients with localized colorectal cancer. However, despite potential curative surgery, the risk of recurrence is high. In colon cancer, the role of adjuvant chemotherapy with 5-fluorouracil (5-FU) and leucovorin (LV) is now established in stage III disease. The benefit of adjuvant treatment in stage II disease is likely to be small, and studies performed thus far have been generally underpowered to detect what might be a clinically significant effect on survival. Whereas bolus scheduling of 5-FU and LV is favored in North America, infusion of 5-FU/LV is preferred in Europe. Indeed, infused 5-FU/LV may be a safer partner with new drugs such as oxaliplatin and irinotecan. Oral fluoropyrimidines are attractive agents that might one day replace parenteral 5-FU. In rectal cancer, postoperative combined chemoradiation was recommended as standard practice in stages II and III disease. Despite a lack of randomized data demonstrating clinical benefit, preoperative chemoradiation has been increasingly used in patients with T3 disease in North America. However, preoperative radiation therapy is more frequently used in Europe. There are discrepancies in pathologic reporting of circumferential resection margin involvement and lymph node status between the United States and Europe. Standardized reporting with improved preoperative imaging would allow patients with truly early-stage disease to undergo more conservative management and be spared the morbidity and mortality of unnecessary adjuvant or neoadjuvant treatment.

Colorectal carcinoma: diagnostic, prognostic, and molecular features

Surgical resection is the primary treatment modality for colorectal cancer, and the pathologic assessment of the resection specimen provides data that is essential for patient management, including the estimation of postoperative outcome and the rationale for adjuvant therapy. The essential elements of the pathological assessment of colorectal cancer resection specimens include the pathologic determination of TNM stage, tumor type, histologic grade, status of resection margins, and vascular invasion. The prognostic and/or predictive value of these elements, as well as guidelines for their derivation and interpretation, are reviewed in detail. Other tissue-based prognostic factors that are strongly suggested by existing data to have stage-independent prognostic value or to predict response to adjuvant therapy but that have not yet been validated for routine patient care are also reviewed. These include perineural invasion, tumor border configuration, host immune response to tumor, and molecular features such as microsatellite instability or loss of heterozygosity of chromosome 18. The need for high-quality, reproducible pathologic data in the care of the colorectal cancer patient, and the dependence of that data on standardization of all aspects of pathological assessment, is emphasized.

Prognosis after rectal cancer in blacks and whites participating in adjuvant therapy randomized trials

PURPOSE

National health statistics indicate that blacks have lower survival rates from colorectal cancer than do whites. This disparity has been attributed to differences in stage at diagnosis and other disease features, extent and quality of treatment, and socioeconomic factors. We evaluated outcomes for blacks and whites with rectal cancer who participated in randomized clinical trials of the National Surgical Adjuvant Breast and Bowel Project (NSABP). The randomized trial setting enhances uniformity in disease stage and treatment plan among all participants.

PATIENTS AND METHODS

The study included black (N = 104) or white (N = 1,070) patients from two serially conducted NSABP randomized trials for operable rectal cancer. Recurrence-free survival and survival were compared using statistical modeling to account for differences in patient and disease characteristics between the groups.

RESULTS

Blacks and whites had largely similar disease features at diagnosis. After adjustment for patient and tumor prognostic covariates, the black/white recurrence hazard ratio (HR) was 1.25 (95% confidence interval [CI], 0.94 to 1.66). The mortality HR was somewhat larger at 1.45 (95% CI = 1.09 to 1.93). Outcomes were improved for both groups in the more recent trial, which employed systemic adjuvant chemotherapy in all treatment arms.

CONCLUSION

Recurrence-free survival was modestly less favorable for blacks, whereas overall survival was more disparate. Outcomes between groups were more comparable than those noted in national health statistics surveys and other studies. Adequate treatment access and the identification of new prognostic factors that can identify patients at high risk of recurrence are needed to ensure optimal outcomes for rectal cancer patients of all racial/ethnic backgrounds.

Pathologic prognostic factors in the recurrence of rectal cancer

For rectal cancer, local recurrence following surgical treatment is a grave complication that occurs in as many as 25% of cases. Pathological examination of the surgical resection specimen plays a primary role in assessing both the surgery- and tumor-related factors that contribute to the risk of recurrence. Among the tumor-related factors, stage has long been considered the single most accurate indicator of survival. However, recent evidence strongly suggests that the most powerful predictor of both local recurrence and overall outcome in the absence of distant metastatic disease is the macroscopic quality of the mesorectum in the resection specimen and the proximity of the tumor to the circumferential (radial) resection margin. Additional pathologic features have been shown to have stage-independent prognostic significance in colorectal cancer and may help to further define risk of adverse outcome. Such features include: tumor grade; histologic type; extent of extramural penetration by tumor; neural, venous, and/or lymphatic invasion; tumor border configuration; tumor budding; and host lymphoid response. The predictive value of tumor-specific molecular features is currently under investigation and may help to further improve prognostication and refine individual patient management in rectal cancer.

Hospital and surgeon procedure volume as predictors of outcome following rectal cancer resection

OBJECTIVE

To compare surgeon and hospital procedure volume as predictors of outcomes for patients with rectal cancer.

SUMMARY BACKGROUND DATA

Although a "volume-outcome" relationship exists for several major cancer operations, the impact of procedure volume on outcomes following rectal cancer surgery remains uncertain, and it has not been determined whether hospital or surgeon volume is a more important predictor of outcomes.

METHODS

A retrospective population-based cohort study utilizing the Surveillance, Epidemiology and End Results (SEER)-Medicare linked database identified 2,815 rectal cancer patients aged 65 and older who had surgery for a primary tumor diagnosed in 1992-1996 in a SEER area. Hospital- and surgeon-specific procedure volume was ascertained based on the number of claims submitted over the 5-year study period. Outcome measures were mortality at 30 days and 2 years, overall survival, and the rate of abdominoperineal resections. Age, sex, race, comorbid illness, cancer stage, and socioeconomic status were used to adjust for differences in case mix.

RESULTS

Neither hospital- nor surgeon-specific procedure volume was significantly associated with 30-day postoperative mortality or rates of rectal sphincter-sparing operations. Although an association between hospital volume and mortality at 2 years was evident, this finding was no longer significant once surgeon-specific volume was controlled for. In contrast, surgeon-specific volume was associated with 2-year mortality and remained an important predictor even after adjustment for hospital volume. Surgeon volume was also better than hospital procedure volume at predicting long-term survival.

CONCLUSIONS

Surgeon-specific experience as measured by procedure volume can have a significant impact on survival for patients with rectal cancer.

Rectal cancer: the sphincter-sparing approach

There is considerable skepticism regarding sphincter-preserving surgery for rectal cancer, and 40% to 60% APR rates are reported in many prospective studies. Despite radical surgery, 20% positive margin rates are frequently reported. Rectal carcinoma responds to preoperative chemoradiation therapy with a 10% to 15% pathologic complete response rate. Preoperative therapy offers an opportunity to reduce the positive margin rate and to reduce the APR rate. Because there is significant tumor regression with preoperative therapy, distal margins of less 1 cm are acceptable and do not result in suture line recurrence. APR rate of less than 10% is feasible and better chemotherapy with radiation therapy will reduce the APR to less than 5%.