Surgical treatment for the recurrence of colorectal cancer

Pulmonary metastasis: rationale for local treatments and techniques

The indication for pulmonary metastasectomy has been postulated based on nonrandomized clinical experiences. The postoperative survival rate of selected patients with pulmonary metastasis is acceptable; nevertheless, pulmonary metastasectomy might cure patients if the neoplastic cells are located only in the lung parenchyma. Computed tomography has been the most reliable preoperative diagnostic methods for identifying pulmonary metastasis. However, it has the limitations that small nodules often cannot be detected, or they are overestimated. Through thoracoscopy, which has largely been applied for metastasectomy in Japan, bimanual palpation during surgery cannot be performed. Considering the fact that the survival rate of the patients undergoing thoracoscopy is not significantly different from that of the patients undergoing conventional thoracotomy, pulmonary metastasectomy is a suboptimal method for eradicating the disease. Less invasive local therapy may be promising for repeat local intervention.

Digest

Dr Keizo Sugimachi, Editor-in-Chief of Surgery Today (The Japanese Journal of Surgery), has selected from the January, February and March 1996 issues of his journal for this quarter's digest. A digest of BJS for the same period written by Mr Colin Johnson, European Editor, appears in the Japanese journal.

Reresection for local recurrence of rectal cancer

Local recurrence is one of the major reasons that rectal cancer surgery is unsuccessful. The aim of this study was to investigate the surgical characteristics of patients undergoing reresection for local recurrence of rectal cancer. A total of nine patients were enrolled in this study, six of whom underwent total pelvic exenteration, one, posterior exenteration, one, abdominoperineal resection with sacral resection, and one, lymph node dissection alone. The mean operative time was 8 h 15 min, and the mean operative blood loss was 2 325 ml. Although major postoperative complications occurred in four patients (44%), there were no postoperative or hospital deaths. Lateral lymph node metastasis was detected in all four patients whose lateral lymph nodes were dissected or extirpated at the reresection. Two patients survived for more than 5 years without rerecurrence, and the cumulative 5-year survival rate was 26%. The para-aortic lymph nodes were the most common site of first rerecurrence. The results of this study indicate that patients who undergo reresection for local recurrence of rectal cancer are at high risk of devel-oping lateral or para-aortic nodal metastasis. Nevertheless, reresection may be a therapeutic option for the local recurrence of rectal cancer.

Surgical treatment for both pulmonary and hepatic metastases from colorectal cancer

OBJECTIVE

The role of surgery in the treatment of patients with pulmonary and hepatic metastases from colorectal cancer has not been delineated.

METHODS

Of the 351 patients enrolled in the Metastatic Lung Tumor Study Group of Japan between June 1988 and June 1996 who underwent thoracotomy for pulmonary metastases from colorectal cancer, 47 also underwent hepatic resection for metastatic tumors. The records of these patients were studied.

RESULTS

The 47 patients who underwent pulmonary and hepatic resection had a 3-year survival of 36% +/- 8%, a 5-year survival of 31% +/- 8%, and an 8-year survival of 23% +/- 9%. The longest survival was 98 months. This patient was alive without recurrence. There was a significant difference in the cumulative survival of the patients with a solitary pulmonary metastasis and the patients with multiple pulmonary metastases (P =.04). Neither age, sex, location of the primary tumor, maximum diameter of the pulmonary metastases, method of pulmonary resection, number of hepatic metastases, nor method of hepatic resection was correlated with survival. However, 9 of 10 patients who survived 3 years or more after the initial thoracotomy had only one or two hepatic metastases.

CONCLUSION

Surgical treatment of a solitary pulmonary metastasis concurrent with or after resection of hepatic metastases from colorectal cancer may be appropriate if the hepatic metastases are resectable for cure. Patients with a solitary pulmonary metastasis and a small number of hepatic metastases are good candidates for resection. Long-term survival can be expected.

Treatment of local recurrence of rectal cancer

BACKGROUND

Treatment of local recurrence of rectal cancer remains a challenge. Preoperative irradiation and total mesorectal excision halve the risks of local failure, but increase morbidity and even mortality. The results of re-resection of recurrent rectal cancer suggest need to reexamine therapeutic strategies for initial treatment.

METHODS

Seventy-one patients operated on for rectal carcinoma without radiotherapy developed local recurrence (29 with metastatic disease). Thirty underwent a curative re-resection (8 had combined resection of metastases).

RESULTS

The incidence of asymptomatic recurrence was higher after anterior resection (38%) than after abdominoperineal resection (16%). The actuarial 5-year survival rate was 19%; 28% in asymptomatic patients and 8% in symptomatic (P = 0.04).

CONCLUSIONS

Early detection of recurrence of rectal cancer leads to an improved re-resection rate and survival. In patients who did not undergo radiotherapy at the time of the original resection, re-resection can be achieved safely. The place for radiation in the treatment of rectal cancer must be redefined.