Incidence and patterns of recurrence following curative resection for colorectal carcinoma

Evaluación de la eficacia y del impacto clínico de la PET-FDG en pacientes con sospecha de recurrencia de cáncer colorrectal

AIMS

To evaluate the utility and clinical impact of Positron Emission Tomography with FDG (FDG-PET) in patients with suspected recurrent colorectal cancer (RCR).

MATERIALS AND METHODS

Eighty five (85) patients with suspicion of RCR (Group A: 35 for increased tumor markers and negative imaging tests, Group B: 25 operable malignant lesions and Group C: 25 with non-conclusive morphological tests) were studied retrospectively. In all patients a whole body scan was performed with FDG-PET. In 29 cases the results were confirmed by histology and clinical evolution (follow-up period > 12 months) and imaging test in 56.

RESULTS

Prevalence of RCR was 89.4 %. FDG-PET was positive in 30/35 patients in Group A, with confirmation in 29 cases (PPV: 96.6 %) and 4/5 were true negative (TN) (NPV: 80 %). FDG-PET enabled surgery for 6 patients. In Group B, PET was positive in 22/25, and all of them had confirmation (PPV: 100 %) but surgery was performed in only 7 patients. NPV was 66.6 %. Out of the 25 cases of Group C, FDG-PET obtained 21 TP, 1 FP case, 1 TN, 2 FN, and was able to avoid surgery in 8 patients (PPV: 95.4 % and NPV: 33.3 %). Overall sensitivity, specificity, PPV, NPV and accuracy were 94.7 %, 77.7 %, 97.2 %, 63.3 % and 92.9 %, respectively.

CONCLUSIONS

FDG-PET has high clinical impact in patients with suspicion of recurrent colorectal cancer, and should be incorporated in the diagnostic protocols before making a surgery decision.

An evidence-based estimate of the appropriate radiotherapy utilization rate for colorectal cancer

PURPOSE

Current estimates of the proportion of cancer patients who will require RT are based almost entirely on expert opinion. The objective of this study was to estimate the proportion of incident cases of colorectal cancer that should receive RT using an evidence-based approach.

METHODS AND MATERIALS

A systematic review of the literature was undertaken to identify indications for RT for colorectal cancer, and to ascertain the level of evidence that supported each indication. An epidemiologic approach was then used to estimate the incidence of each indication for RT in a typical North American population of colorectal cancer patients. The effect of sampling error on the estimated appropriate rate of RT was calculated mathematically, and the effect of systematic error was estimated by sensitivity analysis.

RESULTS

It was estimated that 23.7% +/- 1.0% of colorectal cancer cases develop one or more indications for RT at some point in the course of the illness: 20.9% +/- 1.1% as part of their initial treatment, and 2.8% +/- 0.5% later for recurrence or progression. We estimated that 7.1% +/- 0.8% of colon carcinoma patients will require RT at some point in the course of the illness: 4.0% +/- 0.7% as part of their initial treatment, and 3.1% +/- 0.4% later for recurrence or progression. We estimated that 72.3% +/- 1.0% of rectal carcinoma patients will require RT at some point in the course of the illness: 69.6% +/- 0.9% as part of their initial treatment and 2.7% +/- 0.2% later for recurrence or progression.

CONCLUSIONS

This method provides a rational starting point for the long-term planning of radiation services, and for the audit of access to RT at the population level. By completing such evaluations in the major cancer sites, it will be possible to estimate the appropriate RT treatment rate for the cancer population as a whole.

Tumor microsatellite-instability status as a predictor of benefit from fluorouracil-based adjuvant chemotherapy for colon cancer

BACKGROUND

Colon cancers with high-frequency microsatellite instability have clinical and pathological features that distinguish them from microsatellite-stable tumors. We investigated the usefulness of microsatellite-instability status as a predictor of the benefit of adjuvant chemotherapy with fluorouracil in stage II and stage III colon cancer.

METHODS

Tumor specimens were collected from patients with colon cancer who were enrolled in randomized trials of fluorouracil-based adjuvant chemotherapy. Microsatellite instability was assessed with the use of mononucleotide and dinucleotide markers.

RESULTS

Of 570 tissue specimens, 95 (16.7 percent) exhibited high-frequency microsatellite instability. Among 287 patients who did not receive adjuvant therapy, those with tumors displaying high-frequency microsatellite instability had a better five-year rate of overall survival than patients with tumors exhibiting microsatellite stability or low-frequency instability (hazard ratio for death, 0.31 [95 percent confidence interval, 0.14 to 0.72]; P=0.004). Among patients who received adjuvant chemotherapy, high-frequency microsatellite instability was not correlated with increased overall survival (hazard ratio for death, 1.07 [95 percent confidence interval, 0.62 to 1.86]; P=0.80). The benefit of treatment differed significantly according to the microsatellite-instability status (P=0.01). Adjuvant chemotherapy improved overall survival among patients with microsatellite-stable tumors or tumors exhibiting low-frequency microsatellite instability, according to a multivariate analysis adjusted for stage and grade (hazard ratio for death, 0.72 [95 percent confidence interval, 0.53 to 0.99]; P=0.04). By contrast, there was no benefit of adjuvant chemotherapy in the group with high-frequency microsatellite instability.

CONCLUSIONS

Fluorouracil-based adjuvant chemotherapy benefited patients with stage II or stage III colon cancer with microsatellite-stable tumors or tumors exhibiting low-frequency microsatellite instability but not those with tumors exhibiting high-frequency microsatellite instability.

Angiography for diagnosis and treatment of colorectal cancer

AIM: To evaluate the role of preoperative angiography in the diagnosis and treatment of colorectal cancer.

METHODS: The authors performed selective arterial cannulation by Seldinger's method in 47 patients to locate the primary cancer and to diagnose metastasis to the liver. Each patient was then given intra-arterial regional chemotherapy, and received 5-fluorouracil (5-Fu, 1000 mg), mitomycin C (MMC, 20 mg), and cisplatinum (CDDP, 80 mg).

RESULTS: The location and shape of each tumor were observed, including metastatic tumors in the liver, in 42 of the 47 (89.4%) patients. The site of the primary tumor was difficult to identify in 5 cases because the patients had a recurrence of cancer. Arterial chemotherapy was performed successfully in all patients. The authors recorded no partial or significant morbidity resulted from angiography. The only incident was bleeding from the artery puncture site in one patient, which was successfully stopped by general medication.

CONCLUSION: Preoperative selective arterial angiography can help the diagnosis and locate primary tumors and to detect liver metastasis. At the same time, regional arterial chemotherapy can be an important form of preoperative therapy.

FDG-PET and colon cancer

Imaging colorectal cancer has become a major indication for positron emission tomography using fluorodeoxyglucose (FDG-PET). In primary diagnosis and staging, the role for this technique is limited but FDG-PET has proved highly accurate in the detection of recurrent tumour. The three main indications are (i) characterisation of a residual structural lesion after definitive therapy, (ii) pre-operative staging prior to resection of apparently isolated metastasis, and (iii) investigation of rising carcinoembryonic antigen (CEA) in a patient with normal structural imaging. The diagnostic accuracy of FDG-PET translates to changes in management in a large number of patients, resulting in improved cost-effectiveness. FDG-PET is fast becoming the standard of clinical care for patients with recurrent colorectal cancer.

Multimodality management of locally recurrent colorectal cancer

The combined management of locally recurrent colorectal cancer shows considerable promise, but the best way to incorporate the different treatment modalities and the potential benefits remain uncertain. The case series mentioned here were derived from highly selected groups from a much larger population of patients with recurrent disease; thus fully combined management may be only appropriate for a minority of people with recurrent disease. There is a need for multicenter randomized trials to better delineate the real benefits from the combined approach. Multimodality management of recurrent colorectal cancer, however, involves more than the combination of surgery, radiation therapy, and chemotherapy for a select minority of resectable patients. It involves the use of each modality to its greatest advantage for all patients, as determined by a multidisciplinary team of specialists. We should also not confine our attention to the treatment aspects of recurrent disease alone, as the greatest promise for improved survival could be with a more general application of total mesorectal excision. Because most people who develop local recurrence of colorectal cancer will die from their disease, the main contribution of a multimodality approach may be towards palliation.

Management of recurrent colorectal carcinoma

BACKGROUND/OBJECTIVE: The records of patients treated for adenocarcinoma of the colon and rectum between 1 January 1988 and 31 December 1995 at Naval Medical Center San Diego were reviewed. Analysis was made of patients who developed recurrences after potentially definitive primary therapy. METHODS: A retrospective review of 410 patients diagnosed with colorectal cancer at our institution was conducted. The focus of this review was to identify patients with recurrent disease after curative initial procedures, and to determine how recurrences were detected and treated. Survival data for 48 patients undergoing various curative and palliative procedures, or no therapy, were generated. RESULTS: The decision to re-operate with curative intent was made after a multidisciplinary review of restaging studies. Laparoscopy was not used in this determination. Curative resection of recurrence confers increased survival over non-curative surgery and no surgery (P < 0.001). This is misleading because of patient selection; several patients undergo potentially curative surgery but are determined intraoperatively to best be palliated, or to have further surgery aborted. Analysis of results in patients undergoing potentially curative surgery vs. those undergoing planned palliation vs. those not operated reveals that these also provide significantly different outcomes (P < 0.003). CONCLUSIONS: Proper delineation of resectable lesions in patients with recurrent colorectal cancer contributes to better outcomes for them. That determination is difficult, and efforts are underway in our institution and elsewhere to better delineate which patients are optimal preoperatively. We consider multidisciplinary Tumor Board evaluation to be central to this process.

Locoregional recurrence and survival after curative resection of adenocarcinoma of the colon

BACKGROUND

There is wide variability in reported locoregional recurrence rates after curative resection of adenocarcinoma of the intraperitoneal colon, and there is no universally accepted surgical technique regarding length of the resected specimen or extent of lymphadenectomy. The aim of this study was to determine the disease-free survival, locoregional failure, and perioperative morbidity of patients undergoing curative resection of colon adenocarcinoma.

STUDY DESIGN

The records of 316 consecutive patients undergoing curative resection for primary adenocarcinoma of the intraperitoneal colon between 1990 and 1995 were reviewed. Locoregional recurrence was defined as disease at the anastomosis or in the adjacent mesentery, peritoneum, retroperitoneum, or carcinomatosis. The product-limit method (Kaplan-Meier) was used to analyze survival and tumor recurrence.

RESULTS

The study population comprised 167 men and 149 women, mean age 70+/-12 years (range 22 to 95 years). Median followup was 63+/-25 months. Five-year disease-free survival was 84% overall. Disease-free survival paralleled tumor stage: stage I, 99% (n = 73); stage II, 87% (n = 151); stage III, 72% (n = 92). The predominant pattern of tumor recurrence was distant failure only. Overall locoregional recurrence (locoregional and locoregional plus distant) at 5 years was 4%. Locoregional recurrence paralleled tumor stage: stage I, 0%; stage II, 2%; stage III, 10%. Of the 12 patients who suffered locoregional recurrence, 9 (75%) had T4 primary tumors, N2 nodal disease, or both. Major and minor complications occurred in 93 patients (29%) including: anastomotic leak or intraabdominal abscess (n = 4, 1%); hemorrhage (n = 8, 3%); cardiac complications (n= 17, 5%); pulmonary embolism (n=4, 10%); death (n=2, 1%). Multivariate analysis (Cox proportional hazards) revealed that the only independent predictor of disease-free survival and locoregional control was tumor stage.

CONCLUSION

Longterm survival and locoregional control can be achieved for patients with colon cancer, with low morbidity. In the absence of adjacent organ invasion and N2 nodal disease, locoregional recurrence should be a rare event. Just as for rectal cancer, the technical aspects of colectomy for colon cancer deserve renewed attention.

[Clinical and macroscopic variables that influence the prognosis of colorectal carcinoma]

BACKGROUND AND AIMS

The paradoxical evolution of approximately one third of patients with neoplasms cataloged in Dukes stages B and C demonstrates the desirability of utilizing other prognostic criteria that are capable of broadening the information provided by these two important variables. Only a small number of investigators have dedicated themselves to the study of the prognostic value of clinical and macroscopic parameters of colorectal neoplasms, and the results obtained have been shown to be controversial. The principal aim of this work was to evaluate the prognostic importance of these parameters.

PATIENTS AND METHODS

A study was made of 320 patients with colorectal cancer who underwent curative extirpation. They had a median age of 58 years, and there were 199 females (62.2%) and 121 males (37.8%). The patients were divided into three age groups: under 40 years old, between 40 and 60 years old and over 60 years old. The tumors were distributed in three intestinal segments: right colon, left colon and rectum. The neoplasms were classified as small (diameter less than or equal to 35 mm) and large (diameter greater than 35 mm). With regard to their form, they were classified as exophytic, when characterized by luminal growth, and endophytic, when there was intramural growth. The involvement of the intestinal circumference at the site of the neoplasm was considered as partial or total.

RESULTS

Of the 320 patients, 22 (6.9%) were aged under 40 years, 159 (49.7%) from 40 to 60 years and 139 (43.4%) presented an age of over 60 years. Seventy-three (22.8%) of the neoplasms were located in the right colon, 130 (40.6%) in the left colon and 117 (36.6%) in the rectum. Regarding the size, 280 (87.5%) were large and 40 (12.5%) small; exophytic lesions predominated over endophytic ones - 173 (54.1%) vs 147 (45.9%). A greater number of tumors presented total involvement of the intestinal circumference - 216 (67.5%) - while 104 (32.5%) presented partial involvement. The 5-year survival of the patients was not influenced by their age and sex, or by the location and size of the neoplasms. Exophytic lesions conferred greater survival on their sufferers (65.9%), in comparison with endophytic lesions (49.0%). The survival of patients with lesions partially involving the intestinal circumference was greater than for those with total involvement - 72.1% vs. 51.4%.

CONCLUSIONS

Clinical variables had no influence on the patients' prognosis. Among the macroscopic variables, the form of the neoplasia and its involvement in the intestinal circumference did influence the patients' prognosis. These last two variables are important data capable of contributing to the identification of patient subpopulations with greater or lesser prognostic risk.

Population-based survival analysis of colorectal cancer patients in Singapore, 1968-1992

Since the 1980s, colorectal cancer incidence in Singapore has ranked second to lung in males and females. We describe a population-based analysis of survival of colorectal cancer patients diagnosed from 1968 to 1992 in Singapore. Data of colorectal cancer patients diagnosed during 1968-1992 were retrieved from the Singapore Cancer Registry. Patients were passively followed up for death to the end of 1997. The final dataset consisted of 10,114 subjects. Observed and relative survival rates were calculated by stage (localized, regional metastases and distant metastases), age, ethnicity and calendar period for both genders. Over the study period, a significant progress in survival of colorectal cancer patients was observed. For localized cancer of the colon, the 5-year age-standardized relative survival (ASRS) increased from 36% in 1968-1972 to 66% in 1988-1992 for males and from 32 to 71% for females. For localized rectal cancer, the 5-year ASRS improved from 25 to 66% for males and from 23 to 66% in females. Similarly, improvement was observed in colorectal cancer patients with regional metastases, but not in those with distant metastases. Calendar year period and clinical stage of disease were identified as major significant prognostic factors of survival for colorectal cancer. The substantially improved colorectal cancer survival rates reflected the interplay of cancer control activities in various areas, such as health promotion, early diagnosis and treatment. Our study shows a unique changing pattern of survival experience for colorectal patients from a country undergoing rapid economic development.

Hydronephrosis associated with colorectal carcinoma: treatment and outcome

AIM

Obstruction of the upper urinary tract, hydronephrosis, is not uncommon in the context of primary or recurrent colorectal cancer (CRC). Its presence poses a therapeutic dilemma. This study focuses on the significance of hydronephrosis as a prognostic marker for CRC by analysing the resectability and survival rates of patients affected.

PATIENTS AND METHODS

Retrospective data of 52 patients with hydronephrosis were analysed. Ten had primary CRC at different sites and 42 developed hydronephrosis 1-84 months following resection of a primary CRC. Twenty eight had unilateral and 24 bilateral hydronephrosis.

RESULTS

In 10 patients with primary CRC and in 38 of those with a history of CRC, hydronephrosis was secondary to malignant obstruction. In four it was related to iatrogenic injury to the urinary tract. Complete surgical resection was possible in five patients (10%) with malignant obstruction. The remaining 90% underwent palliative or no surgical treatment due to diffuse metastasis or extensive local disease. No difference in survival was found between these two groups (6 vs 8 months) nor when comparing CEA levels, Duke's staging, or unilateral vs bilateral hydronephrosis. Patients with benign obstruction were treated by a ureteric stent, leading to resolution of hydronephrosis. All four are alive.

CONCLUSIONS

Malignant hydronephrosis, secondary to primary or recurrent CRC, represents local manifestation of a disseminated disease with almost no probability of long-term survival and cure. It would seem that patients with such disease do not benefit from aggressive operations.

Stratifying risk factors for follow-up: a comparison of recurrent and nonrecurrent colorectal cancer

INTRODUCTION

The selection of patients for individualized follow-up and adjuvant therapy after curative resection of colorectal carcinoma depends on finding reliable prognostic criteria for recurrence. However, such criteria are not universally accepted, and follow-up is often standardized for all patients without regard for each individual's level of risk of recurrence. Such a system of follow-up is not cost-effective.

METHODS

A comparison of operative findings, pathologic features, and follow-up data of 1,731 cases of nonrecurrent colorectal cancer (821 colon, 910 rectum) with 357 cases of recurrent colorectal cancer (164 colon, 193 rectum) following potentially curative surgery was made, and results were analyzed to ascertain criteria for stratifying follow-up according to risk factors.

RESULTS

Single-factor analysis showed that Dukes staging and tumor invasion were significantly associated with recurrence in both rectal and colon carcinoma. Tumor fixation and grading were additional significant factors in rectal cancer. Recurrence rates, time to recurrence, site of recurrence (locoregional vs. distant), and pattern of metastatic spread were not significantly affected by original tumor site. Recurrence was not significantly affected by patient age and gender. Individual surgeon performance in this series had also no significant effects on tumor recurrence. With multivariate analysis only, Dukes staging and tumor invasion into adjacent tissues were found to be independent adverse prognostic factors for recurrence.

CONCLUSIONS

Dukes staging and tumor penetration into adjacent tissues are the only significant adverse prognostic factors for tumor recurrence of colonic and rectal carcinoma. Tumor grade and tumor fixation are additional adverse prognostic factors in rectal cancer. Guidelines for follow-up may be based on these factors and follow-up thus stratified according to risk of developing recurrence.

Impact of surgeon organization and specialization in rectal cancer outcome

PURPOSE

The present study was designed to assess the differences in the outcome of patients with rectal cancer treated by a group of surgeons before and after being organized as a Coloproctology Unit at the same University Department of Surgery.

METHODS

Comparison of two periods of rectal cancer surgery: I (1986-91) and II (1992-95). Period I: 94 patients were operated on by 14 general surgeons. Period II: 108 patients were operated on by only 4 surgeons of the same group organized as a Colorectal Surgery Unit after visiting referral centres abroad, adopting techniques such as total mesorectal excision (TME) for middle and low rectal cancer and washout of rectal stump. Mean follow-up during periods I and II was 69.1 and 42.0 months, respectively. A prospective data base analysis was used. Survival and local recurrence rates were calculated by the actuarial method. For comparison between groups the log rank method was used.

RESULTS

The two groups were comparable with respect to mean age, gender, TNM and rectal tumour location. A significant increase in radical resectability and a decrease of the Abdominoperineal resection (APR)/Low anterior resection (LAR) ratio were observed in the second period. The overall pelvic recurrence rate was 25% in the first period and 11 in the second (P < 0.01). Significant differences were also found when the patients with LAR were compared between both periods, 30% vs 9% (P < 0.01) and specially when the 10 cm anal verge distance was considered to divide the LAR groups. No differences were found regarding the APR procedures in both periods. There was improved cancer-specific survival for the LAR group in the second period (P=0.03).

CONCLUSION

Specialization and centralization influence the quality of rectal cancer surgery, mainly local recurrence rates and survival after low anterior resection.

Preoperative serum CD26 levels: diagnostic efficiency and predictive value for colorectal cancer

CD26 is an ectoenzyme with dipeptidyl peptidase IV activity expressed on a variety of cell types. Although the function of the high concentration of serum-soluble CD26 (sCD26) is unknown, it may be related to the cleavage of biologically active polypeptides. As CD26 or enzymatic activity levels were previously associated with cancer, we examined the potential diagnostic and prognostic value of preoperative sCD26 measurements by ELISA in colorectal carcinoma patients. We found a highly significant difference between sCD26 levels in healthy donors (mean 559.7 +/- 125.5 microg l(-1)) and cancer patients (mean 261.7 +/- 138.1 microg l(-1)) (P< 0.001). A cut-off at 410 microg l(-1)gave 90% sensitivity with 90% specificity which means that the diagnostic efficiency of sCD26 is higher than that shown by other markers, particularly in patients at early stages. Moreover, sCD26 as a variable is not related with Dukes' stage classification, age, gender, tumour location or degree of differentiation. With a follow-up of 2 years until recurrence, preliminary data show that sCD26 can be managed as a prognostic variable of early carcinoma patients. In addition, the origin of sCD26 is discussed.

Can postoperative surveillance with serial CEA immunoscintigraphy detect resectable rectal cancer recurrence and potentially improve tumor-free survival?

BACKGROUND

This study was performed to determine if postoperative serial monitoring of rectal cancer patients can be performed with an immunoscintigraphic imaging test for carcinoembryonic antigen (CEA). It was also of interest to assess whether this test, in combination with standard monitoring procedures used in an intensive surveillance plan, can result in the identification of surgically salvageable patients.

STUDY DESIGN

Forty consecutive resected Dukes' B and C rectal cancer patients underwent a prospective, single-institution, surveillance trial of physical examination (including digital rectal examination), endoscopy, CT of the abdomen and pelvis, liver ultrasound, chest x-ray, blood CEA, and CEA immunoscintigraphy with arcitumomab (CEA-Scan, Immunomedics, Morris Plains, NJ) every 6 months for the first 2 years and every 12 months for the next 3 years after initial operation. Outcomes were compared with those from a similar group of 69 patients treated previously at the same institution but without CEA imaging.

RESULTS

A total of 219 CEA imaging studies were performed without any significant adverse effects or immune responses, and resulted in lesion sensitivity, specificity, accuracy, and positive and negative predictive values of 94.1%, 97.5%, 97.3%, 76.2%, and 99.5%, respectively. Of the 40 patients, 16 developed 22 surgically confirmed local or distant recurrences, and CEA imaging correctly disclosed 82% of these lesions pre-operatively. All of the patients found to have recurrences had at least one tumor site by CEA imaging; only 6 of 16 had elevated blood CEA titers. On a patient-basis, there was a sensitivity of 100%, a specificity of 79.2%, an accuracy of 87.5%, and positive and negative predictive values of 76.2% and 100%, respectively. The potential therapeutic benefit of serial arcitumomab imaging is suggested by the fact that 6 of 16 patients (37.5%) with recurrence underwent potentially curative second-look operations, compared with 6 of 69 (8.7%) of a comparable population studied at this institution during an earlier 6-year period, using all of the same tests except CEA imaging. None of the patients in this historic control group survived more than 21 months, although the mean survival of the six patients resected for cure in the study population was 35 months (range 11 to 69 months). During 6 years of followup, three of the six re-resected patients eventually died of cancer recurrence, two died from other causes (and were confirmed by necropsy to be tumor-free), and one patient is still free of disease in the sixth year. CEA scanning appeared to be more predictive of recurrence than blood CEA testing or other diagnostic modalities.

CONCLUSIONS

Arcitumomab inclusion in intensive surveillance of patients with resected rectal cancer can disclose tumor recurrence at a stage that allowed surgical salvage therapy in 37.5% of the 16 patients with recurrence who had second-look surgery, and in 19% the patients were free of disease during longterm followup. This pilot study suggests that a randomized prospective trial comparing standard surveillance procedures to the use of CEA imaging added thereto should be undertaken.

Histologic grade of metastatic lymph node and prognosis of rectal cancer

PURPOSE

It is important to identify cases with a high risk of recurrence to improve the prognosis of colorectal cancer. In this study the difference between the histology of the primary lesion and that of the metastatic lymph node was investigated in an attempt to identify the cases with a high risk of recurrence.

METHODS

One-hundred eighty-five patients with Dukes C rectal cancer who had undergone curative resection were investigated. The histologic grade of the metastatic lymph node was determined and compared with other clinicopathologic factors to determine its significance as a prognostic factor.

RESULTS

The histologic grade was the same between the primary lesion and the metastatic lymph node in 46.2 percent of all cases, although in the group with well-differentiated adenocarcinoma at the primary lesion the concordance was only 29.5 percent. In the group with well-differentiated adenocarcinoma at the primary lesion, the five-year survival rate was 75.3, 64, and 25 percent in the groups with well-differentiated, moderately differentiated, and poorly differentiated adenocarcinoma at the metastatic lymph node, respectively. The differences between the survival rates of well-differentiated and poorly differentiated adenocarcinoma at the metastatic lymph node were statistically significant (P < 0.05). According to multivariate analysis the histologic grade of primary lesion was the most significant prognostic factor (hazard ratio: 2.2801, P = 0.0008). However, in well-differentiated adenocarcinoma of patients with Dukes C rectal cancer at the primary lesion, the histology of metastatic lymph node was also an important prognostic factor.

CONCLUSIONS

It is clear that the histologic grade between the primary lesion and metastatic lymph node was frequently different, especially in the group with well-differentiated adenocarcinoma at the primary lesion. The analysis of the metastatic lymph node was considered to have additional importance for the prediction of prognosis.

Apoptosis in rectal cancer: prognostic significance in comparison with clinical histopathologic, and immunohistochemical variables

PURPOSE

The aim of this study was to evaluate the prognostic value of the apoptotic index for recurrence and disease-free survival after curative surgery for rectal cancer, particularly in relation to clinicopathologic variables, p53- and bcl-2 expression.

METHODS

Formalin-fixed, paraffin-embedded tissue samples of rectal carcinomas resected curatively within a five-year period were used (N = 160). Apoptotic cells with fragmented DNA were detected by the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphatase-biotin nick-end-labeling method. The ratio of apoptotic tumor cells (in percent) was classified into low apoptotic index (less than 10 percent) and high apoptotic index (10 percent or more). Immunohistochemical analysis was performed using monoclonal antibodies (DO-1 for p53 and clone 124 for bcl-2). Statistics included univariate and multivariate analysis, and survival was calculated using the Kaplan-Meier method.

RESULTS

Seventy-five percent of tumors showed a low apoptotic index, and 25 percent had a high apoptotic index. No correlation was found between apoptotic index and International Union Against Cancer stage (P > 0.05). However, significant correlations were documented with histologic differentiation (mean apoptotic index, 5.74 percent in moderately vs. 3.98 percent in poorly differentiated carcinomas; P = 0.0173), lymph node involvement (mean apoptotic index, 6.11 percent in pN1 vs. 3.72 percent in pN2; P = 0.0074), p53 status (mean apoptotic index, 6.26 percent in p53- vs. 4.42 percent in p53+; P = 0.0085), and bcl-2 expression (mean apoptotic index, 5.13 percent in bcl-2- vs. 6.51 percent in bcl-2+; P = 0.0418). Tumors of the lower rectum had a lower apoptotic index than those of the upper rectum (P = 0.0277). Neither univariate nor multivariate analysis assessed apoptotic index as predictor of prognosis: Recurrence rates did not differ between tumors related to apoptotic index (22 percent with low apoptotic index vs. 15 percent with high apoptotic index; P > 0.05), and no significant differences were found regarding survival (P > 0.05). On multivariate analysis, International Union Against Cancer stage (P = 0.0002), p53 (P = 0.0002), gender (P = 0.0136), and bcl-2 (P = 0.0243) were independent predictors of recurrence. These variables, except for bcl-2, were also independently related to disease-free survival.

CONCLUSIONS

Reflecting tumor biology, apoptotic index as single variable showed no prognostic significance, whereas p53 was an independent predictor for both recurrence and survival, and bcl-2 was independently related to recurrence, but not to survival. Clinically, International Union Against Cancer stage and gender were independent prognostic factors after curative surgery for rectal cancer.

Patterns of endoscopic follow-up after surgery for nonmetastatic colorectal cancer

BACKGROUND

Endoscopic examinations of the colon are often recommended for surveillance following colorectal cancer resection. The actual use and outcome of this testing are not known.

METHODS

Five thousand seven hundred sixteen patients 65 years of age or older with local or regional stage colorectal cancer diagnosed in 1991 were identified through the Surveillance Epidemiology and End Results registry. All inpatient and outpatient Medicare claims from 6 months after diagnosis through the end of 1994 were examined to determine use of endoscopic procedures.

RESULTS

One or more colonoscopies were performed in 51%, with an average of 2.9 procedures performed among those tested; sigmoidoscopy was performed in 17%. The rate of colonoscopy was highest during the initial 18 months. Polypectomy was performed in 21% of all patients, and subsequent primary colorectal tumors were diagnosed in 1.3%. Factors associated with colonoscopy and sigmoidoscopy use included younger age, survival through follow-up, and geographic region; sigmoidoscopy was also more common in relation to rectal cancers.

CONCLUSIONS

There is variability in the use of endoscopic procedures following potentially curative resection for colorectal cancer, with patient-related factors and local practice patterns accounting for the variation. Further studies are needed to elicit the reasons for lack of follow-up and adherence to practice guidelines.

Influence of the surgical treatment on local recurrence of rectal cancer: a prospective study (1980-1992)

BACKGROUND AND OBJECTIVES

The incidence of locoregional recurrences (LR) following radical surgery of rectal cancer varies from 5% to 30% according to the literature. The purpose of this prospective study was to compare the outcome of the Abdomino-Perineal Excision (APE) vs. the Anterior Resection (AR) in a consecutive series of 188 patients who underwent surgery for cure from 1980 to the end of 1992 (81 APE and 107 AR), followed for 5 years, evaluating their influence on the incidence of the recurrences.

METHODS

The patients were enrolled at random in the two surgical groups, provided that a radical excision of the tumour, with only two limits: the level of the lesion from the anal verge and the presence of a severe incontinence instrumentally proven. TNM, Dukes staging, grading, and tumour location were statistically evaluated. Further primary suture vs. packing of the perineal wound in APE and handsewn vs. stapled anastomosis in AR were compared in relation with the incidence of LR.

RESULTS

The overall local recurrence rate was 19.2% (32/167), in details 19.7% for APE and 18.5% for AR. Similar recurrence rates were observed following both procedures, matching the patients according to the Dukes stage and different details of techniques. A slight statistically significant difference was found as far as the tumour location is concerned in the group treated with anterior resection (p = <0.05) because of the higher recurrence observed in AR performed for tumours of the lower third of the rectum in comparison with the more proximal level.

CONCLUSIONS

The AA conclude that the choice of the right surgical procedure in the rectal carcinoma depends on the characteristics of the tumour and the conditions of the patients, provided that the oncologic indications were respected, because recurrence and survival rate are independent from the surgical approaches.

p53 and Bcl-2 as significant predictors of recurrence and survival in rectal cancer

The aim of this study was to evaluate the prognostic value of p53 nuclear accumulation and Bcl-2 expression after curative surgery for rectal cancer. Immunohistochemistry was performed using monoclonal antibodies (MAb) (DO-1 for p53; anti-human Bcl-2 MAb, clone 124, for Bcl-2) on formalin-fixed, paraffin-embedded tissues of 160 rectal carcinomas (UICC stages I-III), and results were compared with data from the prospective registry of rectal cancer by univariate and multivariate logistic regression model focusing specifically on recurrence. Survival was calculated by the Kaplan-Meier method and proportional hazards model. p53 nuclear accumulation was documented in 39% (n=63) of tumours and was associated with a higher incidence of tumour progression (local or distant recurrence) and poorer disease-free survival (P<0.0001). Bcl-2 expression was detected in 29% (n=47), and was associated with longer disease-free survival and lower incidence of recurrence (P<0.0086). Multivariate logistic regression analysis demonstrated that gender (P=0.0136), UICC stage (P=0.0002), p53 expression (P=0.0002) and Bcl-2 expression (P=0. 0243) were independent factors predictive of recurrence. The proportional hazards model identified p53 (P=0.0009), UICC stage (P=0.0480), gender (P=0.0049), but not Bcl-2 (P=0.1503), as independently related to disease-free survival. Looking at the p53/Bcl-2 subgroups, the poorest prognosis was observed in the p53+/Bcl-2- subgroup, whereas patients whose tumours were p53-/Bcl-2+ had the best prognosis (P<0.0001). Immunohistochemical assessment of both p53 and Bcl-2 status may be valuable in predicting recurrence and survival after curative surgery for rectal cancer. Therefore, they play a role as prognostic factors in rectal cancer. p53 is a stronger predictor of prognosis than Bcl-2.

Is intensive follow-up really able to improve prognosis of patients with local recurrence after curative surgery for rectal cancer?

BACKGROUND

Because more than 90% of local recurrences after curative surgery for rectal cancer appear within the first 36 months after surgery, an intensive and strict follow-up program during this period could improve early diagnosis and, thus, prognosis of patients.

METHODS

Of the 216 patients who underwent surgery for rectal cancer, 127 entered an intensive follow-up program (median follow-up: 42 months); the clinical outcome of the remaining 89 patients was reconstructed with the help of their general practitioners.

RESULTS

Fifty eight (26.8%) of the 216 patients who were treated with curative surgery alone developed a local recurrence; pelvic recurrences were prevalent. Eleven (30.5%) of the 36 patients who had recurrence during follow-up, and 6 of the 22 who had not undergone follow-up, had a reoperation with curative intent; the median survival was 19 months vs. 8 months, respectively (P = ns). Four (44.4%) curative reoperations were performed on the 9 asymptomatic patients and in 13 (26.5%) of the 49 cases with symptomatic local recurrences. Median survival was 15 months vs. 14 months, respectively (P = n.s). All patients except one (living after 42 months from reoperation) died within 48 months.

CONCLUSIONS

In our study, adherence to a strict follow-up program unfortunately proved to be ineffective for improving long-term survival for patients who underwent reoperation with curative intent.

Distribution of carcinoembryonic antigen and biologic behavior in colorectal carcinoma

PURPOSE

Carcinoembryonic antigen is assumed from the results of several experiments to be associated with invasion of colorectal carcinoma by adhesion or contact inhibition. The patterns and the intensity of carcinoembryonic antigen distribution in colorectal carcinoma were assessed to verify whether they were correlated with malignant potential from those biologic characteristics.

METHODS

Carcinoembryonic antigen distribution was tested in the archival samples of 149 colorectal carcinomas by immunohistochemistry, using three characterized anti-carcinoembryonic antigen monoclonal antibodies: T84.66, PR1A3, and PR3B10. The distribution patterns in neoplastic tissue were categorized into unstained, apicoluminal, and diffuse cytoplasmic patterns. Tumor, invasive tumor margin, and tissue surrounding the tumor were examined.

RESULTS

Although all three antibodies revealed a positive correlation, T84.66 showed better discrimination than the others. Although none of the negative staining of the tumor or invasive tumor margin showed recurrence, the apicoluminal pattern showed recurrence, and the diffuse pattern showed the most frequent recurrence (P < 0.01). Recurrence was also associated with staining intensity in the apicoluminal pattern in both the tumor and invasive tumor margin (P < 0.05). Infiltrative tumor growth and lymph node metastasis were more frequent in cases of positive staining in tissue surrounding the tumor. Patients with the apicoluminal pattern achieved longer survival than patients with the diffuse-cytoplasmic pattern in the invasive tumor margin (P = 0.024) by a multivariate analysis including tumor stage and histologic differentiation.

CONCLUSION

The distribution of carcinoembryonic antigen in tumors and surrounding tissue seems to be closely correlated with invasiveness and metastatic behavior in colorectal carcinoma. Carcinoembryonic antigen immune staining can be considered as an efficient tool to determine groups with risk of recurrence.

Resection of brain metastases from colorectal carcinoma in 73 patients

BACKGROUND

At the time of diagnosis of colorectal carcinoma, 2-3% of patients are likely to be harboring brain metastases, and another 10% of patients will develop brain lesions during the course of their disease. The purpose of this study was to examine the clinical course of a group of patients with metastatic brain disease who underwent surgical resection in a single institution. The authors believe this information will be useful for establishing prognostic factors and for clinical decision making.

METHODS

Between 1974 and 1993, 709 consecutive patients underwent surgical resection of brain metastases at Memorial Sloan-Kettering Cancer Center. Seventy-three patients had histologically confirmed colorectal carcinoma. The medical records of these patients were reviewed retrospectively, and the data were analyzed by univariate and multivariate analysis.

RESULTS

The median age of the 43 women and 30 men was 61.5 years. The median interval from the time of diagnosis of the primary tumor and the development of brain metastases was 27.6 months. The primary colorectal tumor was resected in all patients, and the median survival from the day of surgery was 38 months. The median survival from the time of craniotomy was 8.3 months. The 1-year and 2-year survival rates were 31.5% and 6.8%, respectively. Postoperative mortality was 4%. Gender, presence of multiple metastases, presence of lung lesions, and adjuvant brain radiation after craniotomy appeared to have no impact on survival as determined by multivariate Cox analysis. Only the presence of cerebellar brain metastases was associated with decreased survival.

CONCLUSIONS

The results of this series, which the authors believe is the largest series of resected brain metastases from colorectal carcinoma published to date, indicate that surgical resection may increase the survival of these patients. Analysis of prognostic factors shows that infratentorial tumor location is associated with a poorer survival compared with supratentorial tumor location (5.1 months vs. 9.1 months; P < 0.002). In patients with recurrent brain disease, repeated resection is a worthwhile consideration because it may prolong survival compared with patients who do not undergo re-resection.

Loss of heterozygosity at 18q21 is indicative of recurrence and therefore poor prognosis in a subset of colorectal cancers

Adjuvant therapies are increasingly used in colorectal cancers for the prevention of recurrence. These therapies have side-effects and should, thus, be used only if really beneficial. However, the development of recurrence cannot be predicted reliably at the moment of diagnosis, and targeting of adjuvant therapies is thus based only on the primary stage of the cancer. Loss of heterozygosity (LOH) in the long arm of chromosome 18 is suggested to be related to poor survival and possibly to the development of metastases. We studied the value of LOH at 18q21 as a marker of colorectal cancer prognosis, association with clinicopathological variables, tumour recurrence and survival of the patients. Of the 255 patients studied, 195 were informative as regards LOH status when analysed in primary colorectal cancer specimens using the polymerase chain reaction (PCR) and fragment analysis. LOH at 18q21 was significantly associated with the development of recurrence (P = 0.01) and indicated poor survival in patients of Dukes' classes B and C, in which most recurrences (82%) occurred. An increased rate of tumour recurrence is the reason for poor survival among patients with LOH at 18q21 in primary cancer. These patients are a possible target group for recurrence-preventing adjuvant therapies.

Outcome of large-bowel perforation in patients with colorectal cancer

PURPOSE

Perforation of the colon is seldom associated with malignant disease. Operative mortality varies widely in published studies and little is known about patterns of failure and long-term outcome. An observational study was undertaken to assess the outcome of colorectal cancer complicated by perforation.

METHOD

We reviewed a series of 83 consecutive patients treated during a 14-year period at one institution.

RESULTS

Fifty-four (65 percent) patients had perforation of the tumor itself, and 29 (35 percent) had diastatic perforation proximal to an obstructing tumor. Twenty-six (31.5 percent) patients had metastatic disease at laparotomy. Primary resection of the diseased segment was performed in 47 (87 percent) patients with perforation of the tumor itself and in 21 (72.4 percent) patients with diastatic perforation proximal to an obstructing tumor. However, only 57 patients (39 (72.2 percent) with perforation of the tumor itself; 18 (62 percent) with diastatic perforation proximal to an obstructing tumor; P = not significant) were potentially cured. Operative mortality was 16.7 and 48.3 percent, respectively (P < 0.01) and correlated significantly with Hinchey's stage (P < 0.001) and advanced disease (P = 0.023). At a mean follow-up of 43 (median 31) months, 21 (46 percent) of the 46 potentially cured survivors were alive. The local recurrence rate was 22.9 percent in patients with perforation of the tumor itself and 18.2 percent in patients with diastatic perforation proximal to an obstructing tumor (P = not significant). Peritoneal seeding occurred in 17 and 0 percent (P = not significant); the mean disease-free interval was 33.9 and 49.9 months (P = not significant); and five-year cumulative disease-related survival probability was 0.51 and 0.90 (P = 0.049), respectively.

CONCLUSIONS

Diastatic perforation proximal to an obstructing tumor is associated with higher operative mortality and better cancer-related survival than a tumor perforating through the bowel wall. Early diagnosis in diastatic perforation and aggressive management of sepsis associated with radical surgical resection is recommended.