Enhanced growth of tumour cells in healing colonic anastomoses and laparotomy wounds

Anastomotic Leak Impact on Long-Term Survival after Right Colectomy for Cancer: A Propensity-Score-Matched Analysis

Our goal was to assess the impact of anastomotic leaks (ALs) on oncologic outcomes using a case-matched analysis. Patients undergoing right hemicolectomy for cancer between 2014 and 2018 were included. The main variables were the risk factor of anastomotic leak, overall survival and disease-free survival. Propensity score matching was performed according to the patient’s age, co-morbidities and TNM staging as well as the type of procedure. Oncologic outcomes were analyzed. We included 488 patients and performed final analysis on 69 patients. The AL rate was 4.71% (23 patients). Intrahospital mortality was significantly higher in the AL group, at 1.3% (6 of 465) vs. 8.7% (2 of 23), p = 0.05. Three-year overall survival (OS) in the non-AL group was higher, although the difference could not be considered significant (71.5% vs. 37.3%, p = 0.082); similarly, the likelihood for impaired 3-year progression-free survival (PFS) was lower, but the difference here could also not be considered significant (69.3% vs. 37.3%, p = 0.106). Age, advanced tumor stage, lymph node metastases and distant metastases were associated with higher probability of death or recurrence of disease. In contrast, minimally invasive surgery was associated with lower probability of death (HR (95% CI): 0.99 (0.14–0.72); p = 0.023) and recurrence of disease (HR (95% CI): 0.94 (0.13–0.68); p = 0.020). In an adjusted Cox regression analysis, AL, age and distant metastases were associated with poor long-term survival. Moreover, AL, age and distant metastases were associated with higher probability of recurrence of disease. Based on our results, AL is a significant factor for worse oncologic outcomes. Simple summary: we aimed to assess patients with anastomotic leaks following right hemicolectomy for cancer. These patients were matched to patients without leaks. Propensity score analysis demonstrated that anastomotic leak was a marker of worse oncologic outcomes.

Neuroimmune Regulation of Surgery-Associated Metastases

Surgery remains an essential therapeutic approach for most solid malignancies. Although for more than a century accumulating clinical and experimental data have indicated that surgical procedures themselves may promote the appearance and progression of recurrent and metastatic lesions, only in recent years has renewed interest been taken in the mechanism by which metastasizing of cancer occurs following operative procedures. It is well proven now that surgery constitutes a risk factor for the promotion of pre-existing, possibly dormant micrometastases and the acceleration of new metastases through several mechanisms, including the release of neuroendocrine and stress hormones and wound healing pathway-associated immunosuppression, neovascularization, and tissue remodeling. These postoperative consequences synergistically facilitate the establishment of new metastases and the development of pre-existing micrometastases. While only in recent years the role of the peripheral nervous system has been recognized as another contributor to cancer development and metastasis, little is known about the contribution of tumor-associated neuronal and neuroglial elements in the metastatic disease related to surgical trauma and wound healing. Specifically, although numerous clinical and experimental data suggest that biopsy- and surgery-induced wound healing can promote survival and metastatic spread of residual and dormant malignant cells, the involvement of the tumor-associated neuroglial cells in the formation of metastases following tissue injury has not been well understood. Understanding the clinical significance and underlying mechanisms of neuroimmune regulation of surgery-associated metastasis will not only advance the field of neuro–immuno–oncology and contribute to basic science and translational oncology research but will also produce a strong foundation for developing novel mechanism-based therapeutic approaches that may protect patients against the oncologically adverse effects of primary tumor biopsy and excision.

Risk factors for anastomotic leakage and its impact on long-term survival in left-sided colorectal cancer surgery

Background

Anastomotic leakage (AL) significantly impairs short-term outcomes. The impact on the long-term outcomes remains unclear. This study aimed to identify the risk factors for AL and the impact on long-term survival in patients with left-sided colorectal cancer.

Methods

Nine-hundred patients with left-sided colorectal carcinoma who underwent sigmoid or rectal resection were enrolled in the study. Risk factors for AL after sigmoid or rectal resection were identified, and long-term outcomes of patients with and without AL were compared.

Results

AL rates following sigmoid and rectal resection were 5.1% and 10.7%, respectively. Higher ASA score (III–IV; OR = 10.54, p = 0.007) was associated with AL in patients undergoing sigmoid surgery on multivariable analysis. Male sex (OR = 2.40, p = 0.004), CCI score > 5 (OR = 1.72, p = 0.025), and T3/T4 stage tumors (OR = 2.25, p = 0.017) were risk factors for AL after rectal resection on multivariable analysis. AL impaired disease-free and overall survival in patients undergoing sigmoid (p = 0.009 and p = 0.001) and rectal (p = 0.003 and p = 0.014) surgery.

Conclusion

ASA score of III–IV is an independent risk factor for AL after sigmoid surgery, and male sex, higher CCI score, and advanced T stage are risk factors for AL after rectal surgery. AL impairs the long-term survival in patients undergoing left-sided colorectal surgery.

Hepatectomy increases metastatic graft and growth in an immunocompetent murine model of peritoneal metastases

BACKGROUND

Curative surgery of synchronous peritoneal metastases (PM) and colorectal liver metastases (LM) has been recently investigated as feasible option. When synchronous peritoneal and liver resection is not achievable, the sequence of the surgery remains unknown. Our hypothesis was that liver resection (LR) promotes peritoneal growth resulting in a non-resectable PM. We sought to analyse the effects of major LR and liver regeneration after hepatectomy in a murine model of PM and the associated angiogenesis.

METHODS

Murine model of colorectal PM in Balb/C mice was developed by intraperitoneal injection of different CT-26 tumour cell concentrations. Five days after the injection, mice were randomized into three groups: 68% hepatectomy group, sham laparotomy and control group without surgery. On post-operative days 1, 5 and 20, PM was evaluated macroscopically, tumour growth and liver regeneration by immunohistochemistry, and angiogenesis by immunofluorescence. Circulating progenitor cells, plasmatic cytokines and digestive arterial blood flow velocity measurements were also analysed.

RESULTS

Reproducible murine model of limited colorectal PM was obtained. Surgery induced PM increases and promoted neo-angiogenesis. Major hepatectomy influence the tumour growth in the late phase after surgery, the extent of extra-peritoneal metastasis and the increase of Ki-67 expression in the remnant liver.

CONCLUSIONS

This animal model confirms the pro-tumoural and pro-angiogenic role of surgery, laparotomy and major LR, which promotes the increase of angiogenic factors and their participation in PM growth. These results suggest that peritoneal resection should be first step in the case of two-step liver and peritoneal surgery for patients with colorectal PM and LM.

Intraluminal ileal tumour after right hemicolectomy for cancer: An implantation recurrence or a new cancer? A case report

Introduction

Extra-anastomotic intraluminal recurrence of the colon cancer after curative surgery was rarely reported but intraluminal ileal relapse has not been described to date.We report a case of intraluminal ileal tumor arising after curative right hemicolectomy that could be ascribed to an implantation of exfoliated cancer cells.

Case report

A 71-years old man was admitted with no metastatic stenotic adenocarcinoma of the hepatic flexure and submitted, without preoperative bowel preparation, to right hemicolectomy using a "no-touch" technique. Histology showed moderately differentiated adenocarcinoma without lymph nodes involvement (pT3N0). No adjuvant therapy was prescribed. First colonoscopy three months after surgery was negative but a second endoscopic examination nine months later revealed an ileal neoplasia, presenting like an ulcer 10 cm proximally to ileocolic anastomosis. A new ileo-colic resection including past anastomosis was performed with curative intent. Pathological examination showed moderately differentiated adenocarcinoma extended to peri-visceral fat tissue with 10 tumor-free lymph nodes. (pT3N0). Six courses of Capecitabine adjuvant chemotherapy was prescribed and 32 months after second surgery, the patient is alive without disease.

Discussion

In the present case, the relatively short time from the primary surgery and the fact that recurrence occurred outside the anastomosis suggest that implantation of exfoliated malignant cells seems to be the main pathogenetic mechanism. We suppose that the high grade of primary cancer and the occlusive condition could have promoted the cancer cells reflux through the ileocecal orifice and in the transverse colon.

Conclusion

This case seems to confirm the intraluminal implanting capacity of exfoliated carcinoma cells.

Port site recurrence after laparoscopic radical nephrectomy: a case report

Background

Due to the recent development of laparoscopic devices, laparoscopic radical nephrectomy is the standard procedure for localized renal cell carcinoma. However, some studies have reported postoperative port site metastasis in several cancers.

Case presentation

A 68-year-old Asian-Japanese man was referred to our hospital for a further examination of his right renal tumor in 2009. Due to a clinical suspicion of renal cell carcinoma, laparoscopic nephrectomy was performed. The histopathological diagnosis was clear cell renal cell carcinoma. Follow-up computed tomography revealed a mass between the internal oblique muscle of his abdomen and the transverse muscle of his abdomen in 2014. The tumor size gradually increased, and positron emission tomography-computed tomography revealed the accumulation of fludeoxyglucose in that tumor with maximum standardized uptake value of 2.7. Based on these findings, port site recurrence was suspected, and tumor resection was performed in 2017. The pathological diagnosis was metastatic clear cell renal cell carcinoma.

Conclusions

Here we report a rare case of port site metastasis that was successfully treated 7 years after laparoscopic nephrectomy.

Port site metastasis after surgery for renal cell carcinoma: harbinger of future metastasis

PURPOSE

Port site metastasis is a rare occurrence after minimally invasive treatment for renal cell carcinoma. However, its prognostic implications are unclear because reports in the literature are heterogeneous in detail and followup. We clarify the significance of port site metastasis in cancer specific survival and broaden our understanding of this phenomenon.

MATERIALS AND METHODS

A MEDLINE® search for published studies of renal cell carcinoma port site metastasis was performed. Contributing factors to port site metastasis, stage, Fuhrman grade, pathology, port site metastasis treatment method, followup protocol and long-term outcomes were collected. The corresponding authors of each publication were contacted to fill in details and provide long-term outcomes. We added 1 case from our recent experience.

RESULTS

A total of 16 cases from 12 authors (including ourselves) were found. Of the 12 authors 8 were available for correspondence and 9 cases were updated. Eventual outcomes were available for 11 of the 16 cases and survival curves showed poor prognosis with a 31.8% overall 1-year survival rate. Of the 16 cases 12 were radical nephrectomy and 4 were partial nephrectomy, and 13 involved multiple metastases in addition to the port site metastasis. Nine of the cases had no identifiable technical reason for port site metastasis formation such as specimen morcellation, absence of entrapment or tumor rupture. These tumors were uniformly aggressive, Fuhrman grade 3 or higher.

CONCLUSIONS

Port site metastasis after minimally invasive surgery for renal cell carcinoma is a rare occurrence with a poor prognosis. In most cases port site metastasis is not an isolated metastasis but instead is a harbinger of progressive disease. While technical factors can have a role in port site metastasis formation, it appears that biological factors like high tumor grade also contribute.

Evaluation of the presence of intraluminal cancer cells following rectal washout in rectal cancer surgery

BACKGROUND

The presence of intraluminal tumour cells in colorectal cancer is known, as is their ability to implant in colorectal anastomoses, causing perianastomotic tumour growth. There is no consensus as to the volume and agent to use for rectal washout. The purpose of this study was to assess the efficacy of our current routine for rectal washout in eliminating intraluminal tumour cells.

METHODS

Sixty consecutive patients undergoing low anterior resection or low Hartmann's procedure for rectal cancer at our unit were included. After the pelvic dissection was completed, the bowel was cross-clamped distal to the tumour and the prewashout sample (no. 1), was obtained by instilling 50 ml of saline and collecting the return fluid. A rectal washout followed using 500 ml of sterile water, 2 × 500 ml of 70 % ethanol and 500 ml of sterile water (sample no. 2-4) and the postwashout sample (no. 5) was obtained by using 50 ml of saline. The samples were examined and categorized as non-malignant or malignant at the Department of Pathology. The usual pathology report information was also assessed.

RESULTS

In 33 of the 60 patients, cancer cells were identified in the prewashout sample. The rectal washout eliminated intraluminal cancer cells in 30 of the 33 patients. All of the remaining 3 had a higher blood loss (p = 0.026) and a tendency towards more polypoidal tumours (p = 0.053).

CONCLUSIONS

A rectal washout volume larger than 2,000 ml might be necessary to eliminate all intraluminal tumour cells in total mesorectal excision for rectal cancer.

Camera-port site metastasis of a renal-cell carcinoma after robot-assisted partial nephrectomy

BACKGROUND AND PURPOSE

Port-site metastasis (PSM) is a rare complication of laparoscopic intervention in urologic malignancies. Of the greater than 50 reported cases of PSM in the urologic oncology literature, only 9 have occurred after surgery for renal-cell carcinoma (RCC). We report a 10th instance of RCC metastasis-in this case to the camera-port site after robot-assisted partial nephrectomy (RAPN). To our knowledge, this case is the first reported PSM of RCC after RAPN.

PATIENT AND METHODS

A 68-year-old man underwent an uncomplicated right RAPN for a 4-cm right renal mass (stage T1aN0M0). Five months later, he was found to have metastatic disease with an isolated peritoneal recurrence at the camera-port site. Biopsy of the lesion confirmed RCC, and the lesion was surgically resected. A comprehensive MEDLINE search for all published studies of port-site recurrences after laparoscopic renal surgery for RCC was performed.

RESULTS

Nine cases of PSM after successful laparoscopic radical or partial nephrectomy for locally confined RCC have been reported. Proposed etiologic factors for port-site recurrence include biologic aggressiveness of the tumor, patient immunosuppression, local wound factors, and technique-related factors. We report an unusual case of PSM to a camera port that was not used for specimen manipulation or extraction.

CONCLUSION

PSM after laparoscopic renal surgery for RCC is a rare occurrence. Our case, in which PSM occurred without specimen bag rupture or extraction through the port in question, highlights the importance of local and systemic factors in contributing to PSM occurrence. We also demonstrate that when PSM is the only site of disease recurrence, it can be successfully managed with minimally invasive surgical resection.

Surgical injury enhances the expression of genes that mediate breast cancer metastasis to the lung

OBJECTIVE

This study was conducted to test the hypothesis that surgery induces changes at the expression level of genes implicated in metastasis, thus leading to accelerated postoperative metastatic tumor growth.

SUMMARY BACKGROUND DATA

Surgical resection of the primary tumor is a necessary and effective treatment for breast cancer patients. However, studies from both animals and humans have shown that surgery potentiates the growth of minimal residual neoplastic disease.

METHODS

: Female BALB/c mice were inoculated with metastatic murine mammary adenocarcinoma 4T1-green fluorescent protein (GFP) cells in the mammary fat pad (3 × 10⁵/mouse), and divided into a surgery group (n = 12) in which the flank tumor was completely resected after 21 day growth and a control (no surgery) group (n = 12). Metastatic tumor burden was assessed by both macroscopic metastatic nodule count and clonogenic assay. Mitotic and apoptotic indices were established using a combination of hematoxylin-eosin histology and Ki-67 immunohistochemistry. Green fluorescent protein (GFP) expressing tumor cells were isolated using FACS sorting, and RNA was extracted. The RT² Profiler PCR Array mouse Cancer Pathway Finder was used to determine and compare the mRNA levels of 84 genes involved in metastasis in both groups.

RESULTS

Excision of the primary tumor was associated with increased systemic metastatic burden (P = 0.001). Postoperative metastases exhibited increased proliferation (P = 0.001), but no reduction in apoptosis. The quantitative real-time polymerase chain reaction array data indicate that surgery significantly upregulated the expression of Itgb3, Egfr, Hgf, Igf1, Pdgfb, Tnfα, Vegfa, Vegfc, and MMP9 genes, and led to the down regulation of Cdkn2a, Cdh1, and Syk genes. Increased expression of ITGB3 and MMP9 was further confirmed at the protein level by Western blot.

CONCLUSIONS

Removal of the primary tumor led to a progressive phenotype of lung metastases that exhibited upregulation of genes involved in adhesion, invasion, and angiogenesis.

Expression of metalloproteases and their inhibitors in primary tumors and in local recurrences after mastectomy for breast cancer

AIMS

To investigate the expression of matrix metalloproteases (MMPs) and their inhibitors (TIMPs) in patients who develop local recurrence (LR) after mastectomy.

METHODS

We analyzed the expressions of MMP-1, -2, -7, -9, -11, -13, -14, TIMP-1, -2, and -3, using immunohistochemical techniques, in primary tumors from patients without tumoral recurrence (n = 50), patients who developed distant metastasis (n = 50), and from patients who develop LRs (n = 25). LRs of the latter group were also analyzed for MMPs expression. All the patients underwent mastectomy.

RESULTS

Score values for all MMPs and TIMPs were significantly higher in primary tumors of patients with distant metastasis. Primary tumors from patients with LR have lower expressions of MMPs and TIMPs compared with those from patients who developed distant metastasis, and with patients without recurrence for some MMPs. Remarkably, however, primary tumors from patients with LR showed significantly higher percentage of TIMP-1 and 2 expression in stromal cells compared to primary tumors from patients with distant metastasis or primary tumors from patients without tumoral progression. Furthermore, LRs had significantly higher MMP-9 expression than their corresponding primary tumors.

CONCLUSIONS

Our data indicate differences in MMPs/TIMPs expression between primary tumors of patients with LRs and of those with distant metastasis, both after mastectomy for breast cancer.

Benefits of povidone-iodine solution in colorectal operations: science or legend

Povidone-iodine solution (Betadine) has long been accepted as an effective topical broad spectrum antiseptic, disinfectant, and tumoricidal agent. In colorectal operations, this solution generally has been used for the purpose of minimizing postoperative septic complications and reducing cancer recurrence, although the optimal application, advantages, and undesirable side effects have been debated. With limited prospective, randomized, controlled trials and insufficient data available, this article examines the safe and effective clinical applications of this solution for colorectal operations.

Local recurrence after mastectomy for breast cancer: analysis of clinicopathological, biological and prognostic characteristics

BACKGROUND

Despite the increasing use of breast-conserving therapy, modified radical mastectomy retains an important role in primary as well as in salvage treatment of breast cancer. Nevertheless, a significant number of patients will eventually develop a local recurrence (LR).

AIMS

To identify the potential prognostic factors at the time of the first isolated LR, and to compare the expression of several parameters of the molecular biology of breast carcinomas by primary tumors and paired isolated LRs.

METHODS

We analyzed the medical records from 1,087 women who underwent mastectomy for breast cancer, out of which 98 developed LRs as the first manifestation of tumor progression. We investigated the prognostic value of various classical prognostic factors, at the time of mastectomy as well as when the diagnosis of LR was made. In addition, by using tissue microarrays and immunohistochemical techniques, we analyzed the expression of estrogen (ER), progesterone (PR) and androgen receptors (AR), ki67, p53, c-erbB-2 and apolipoprotein D in primary tumors and paired isolated LRs from a subset of patients (n = 25).

RESULTS

Patients who developed distant metastases as well as patients with local recurrent disease showed a significantly higher percentage of larger tumors, node-positive status and higher tumoral grade than patients without evidence of tumoral recurrence. Furthermore, patients with LR had a better outcome compared with those with distant metastases, although the former received less frequently adjuvant systemic therapy and/or radiotherapy. Tumor size, histological grade, ER and PR status, and a shorter disease-free interval (<12 months) were significantly associated with overall survival amongst mastectomized patients that developed isolated LR. There was a significant concordance between primary tumors and LRs regarding the expression of the following factors: ER, PR and p53. However, we were not able to demonstrate similar findings for AR, c-erbB-2 and ki67. In addition, ER, PR and p53 status in the LRs were significantly associated with a poorer overall survival.

CONCLUSIONS

Based on classical clinicopathological factors as well as on some new biological parameters we have been able to identify subgroups of mastectomized patients with LR differing in their prognosis. Thus, at the present time it would be possible to select group of patients candidates for further and individualized therapeutic strategies.

Cancer surgery: risks and opportunities

In the recent past, several papers have pointed to the possibility that tumour removal generates a permissive environment in which tumour growth is potentiated. This phenomenon has been coined "perioperative tumour growth" and whilst it represents a departure in terms of our attitude to the surgical process, this concept was first hinted at by Paget(1) himself. Despite this, the time interval immediately before and after cancer surgery (i.e. the perioperative period) remains an underutilised interval during which chemotherapeutic regimens are rarely implemented. Herein, we present a summarised review of the literature that supports the concept that tumour removal may potentiate the growth of residual neoplastic disease. We also outline current knowledge regarding underlying mechanisms and in this manner highlight potential therapeutic entry points. Finally, we emphasise the urgent need for trials of agents that could protect patients against the harmful host-tumour interactions that may occur during the perioperative period.

Reduction of abdominal wall blood flow by clamping or carbon dioxide insufflation increases tumor growth in the abdominal wall: an experimental study in rats

BACKGROUND

We have previously demonstrated that there is a reduction of blood flow in the abdominal wall in rats insufflated with air concomitant with an increase in tumor growth. The present study was designed to examine whether a reduction of blood flow achieved by clamping or insufflation with carbon dioxide (CO(2)) would increase tumor growth in the abdominal wall.

METHODS

In the first part of the experiments, laser Doppler blood flow of both rectus muscles was measured in 16 Wistar Fu rats. The left rectus muscle was clamped to reduce blood flow, and 5 x 10(4) adenocarcinoma cells were injected into both rectus muscles. Clamping was maintained for 45 min. In the second part, 22 rats had 5 x 10(4) adenocarcinoma cells injected into the rectus muscle and blood flow was measured. The experimental group (n = 11) was insufflated with CO(2) at 10 mmHg for 45 min; the control group (n = 11) was not insufflated. After 9 days, tumor weight and volume were analyzed.

RESULTS

Clamping caused a 69% reduction of blood flow (p < 0.001), whereas no reduction was registered on the nonclamped side. Tumor weight (p = 0.028) and volume (p = 0.030) were increased on the clamped side. The insufflation of CO(2) caused a 71% reduction of blood flow, whereas no reduction was registered in the control group. Tumor weight (p = 0.006) and volume (p = 0.006) were increased in the insufflated group.

CONCLUSION

Clamping, as well as CO(2) insufflation, causes a significant reduction of blood flow in the abdominal wall, which seems to increase tumor growth at the same site.

Surgery and angiogenesis

Surgery may be regarded as an angiogenesis-inducing condition since it evokes the release of many angiogenic factors. Regarding the mechanistic overlap between tumor-associated neovascularisation and (physiological) angiogenesis in response to injury and hypoxia, surgery may promote the uncontrolled growth of residual dormant tumor cells. With the advent of anti-angiogenic agents, surgeons will be faced with more patients undergoing surgery for primary and secondary tumors under anti-angiogenic treatment. This could present problems with regard to angiogenesis-dependent phenomena such as wound repair, healing of intestinal anastomoses and liver regeneration. In this review we will discuss these matters from a biomedical and clinical point of view.

Pneumoperitoneum impairs blood flow and augments tumor growth in the abdominal wall

BACKGROUND

Despite several clinical and experimental studies, the mechanisms behind the development of port site metastases in laparoscopic surgery have remained largely unknown. The current study was designed to investigate the effect of pneumoperitoneum on blood flow in the abdominal wall and its possible effects on tumor growth at this site.

METHODS

A total of 40 Wistar Fu rats had a laser Doppler probe placed on their left rectus muscle and a suspension of 50,000 adenocarcinoma cells was injected into their right rectus muscle. The experimental group (n = 20) was insufflated with air at 10 mmHg for 45 min while abdominal blood flow was registered before and during insufflation and after exsufflation. The control group (n = 20) was not insufflated but the blood flow was recorded in the same manner. After 9 days, all animals were killed and the occurrence of tumor was observed. The tumors were analyzed with respect to weight and volume.

RESULTS

The insufflation caused an 82% reduction in blood flow in the experimental group (p < 0.001). No reduction in blood flow was registered in the control group. Tumor nodules developed significantly more often in the insufflated group (20/20) compared to the controls (14/20) (p = 0.016). Tumor weight (p = 0.003) and volume (p < 0.001) were significantly increased in the insufflated group.

CONCLUSIONS

Pneumoperitoneum seems to enhance tumor growth. It also causes a significant reduction in blood flow in the abdominal wall, which may contribute to the increased susceptibility of tumor take.

Port site metastases in urological laparoscopic surgery

PURPOSE

Laparoscopic surgery is rapidly gaining widespread acceptance among urologists, including extensive application in malignant conditions. However, untoward occurrences of port site metastases have not eluded to urological applications. This up-to-date review on port site metastases in urology delineates possible contributing factors and describes techniques to prevent it.

MATERIALS AND METHODS

We comprehensively reviewed published experimental and clinical studies with special emphasis on the incidence, pathophysiology and prevention of port site metastases.

RESULTS

Nine cases of port site metastases after urological laparoscopy have been described in clinical and experimental studies. Etiological factors include natural malignant disease behavior, host immune status, local wound factors, laparoscopy related factors such as aerosolization of tumor cells (the use of gas, type of gas, insufflation and desufflation, and pneumoperitoneum) and sufficient technical experience of the surgeons and operating team (adequate laparoscopic equipment, skill, minimal handling of the tumor, surgical manipulation and wound contamination during instruments change, organ morcellation and specimen removal).

CONCLUSIONS

Port site metastases is a multifactorial phenomenon with an as yet undetermined incidence. The problem is influenced to some extent by surgeon and operating team experience and, therefore, it could be partially prevented. The suggested preventive steps are avoiding laparoscopic surgery when there are ascites, trocar fixation to prevent dislodgment, avoiding gas leakage along and around the trocar, sufficient technical readiness of the operating team (adequate laparoscopic equipment and technique, minimal handling and avoiding tumor boundary violation of the tumor), using a bag for specimen removal, placing drainage when needed before desufflation, povidone-iodine irrigation of instruments, trocars and port site wounds, and suturing 10 mm. and larger trocar wounds.

Paclitaxel loaded poly(L-lactic acid) microspheres for the prevention of intraperitoneal carcinomatosis after a surgical repair and tumor cell spill

A controlled release delivery system for paclitaxel was developed using poly(L-lactic acid) to provide local delivery to the peritoneal cavity. Microspheres were made in 1-40 and 30-120 microm size ranges. In an in vitro release study, 30-120 microm microspheres loaded with 10, 20 and 30% paclitaxel exhibited a burst phase of release for 3 days followed by an apparently zero-order phase of release. At all loadings, 20-25% of the original load of paclitaxel was released after 30 days. The effect of microsphere size on retention in the peritoneal cavity was assessed. Control 1-40 microm microspheres were injected intraperitoneally in rats. The rats received either insufflation of the peritoneal cavity using 11 mmHg CO2 or no further treatment. After sacrifice, microspheres with diameters less than 24 microm were observed in the lymphatic system after being cleared from the peritoneal cavity through fenestrations in the diaphragm. Insufflation of the peritoneal cavity had no effect on the size of microspheres that were cleared. Efficacy studies were carried out using 30-120 microm microspheres that were of sufficient size to be retained in the peritoneal cavity. In a model of a tumor cell spill after a cecotomy repair, 100 mg of 30-120 microm microspheres containing 30% paclitaxel were effective in preventing growth of tumors in the peritoneal cavity at both 2 and 6 weeks post-surgery. No gross or histologically evident tumor growth was observed on any peritoneal surfaces or in the surgical wound site. Rats receiving control microspheres all showed tumor cell implantation and growth after 2 weeks.

Wound recurrence from gallbladder cancer after open cholecystectomy

BACKGROUND

Reports of port site recurrences from gallbladder cancer after laparoscopic cholecystectomy have raised considerable concern as to whether the laparoscopic technique implies an increased risk of metastatic disease. In a previous study of gallbladder cancer and laparoscopic cholecystectomy, we reported a frequency of 16% port site metastases. The purpose of the present study was to determine the frequency of wound metastases from gallbladder cancer after open cholecystectomy.

METHODS

The registers from the Swedish Oncological Centers and the National Board of Health and Welfare were checked for reported cases of gallbladder cancer and surgical classification codes for open cholecystectomy from 1991 to 1994. The study included all 8 university and 24 county hospitals in Sweden. The files from all patients with gallbladder cancer who had an open cholecystectomy were retrospectively reviewed.

RESULTS

The study included 270 patients who had a cholecystectomy, of which 215 were classified as open and 55 as laparoscopic. Of the 215 patients, 11 patients were excluded because of an incorrect or deficient histopathologic or surgical classification. In 186 patients (91%), sufficient data were obtained for follow-up. Twelve patients (6.5%) had wound metastases from their gallbladder cancer. All patients with wound metastases died with a median survival of 10 months (range, 3 to 65 months).

CONCLUSIONS

Wound metastases from gallbladder cancer after open cholecystectomy may be more common than previously assumed.

The role of endotoxin/lipopolysaccharide in surgically induced tumour growth in a murine model of metastatic disease

Surgical removal of a primary tumour is often followed by rapid growth of previously dormant metastases. Endotoxin or lipopolysaccharide, a cell wall constituent of Gram-negative bacteria, is ubiquitously present in air and may be introduced during surgery. BALB/c mice received a tail vein injection of 10(5) 4T1 mouse mammary carcinoma cells. Two weeks later, animals were subjected to surgical trauma or an intraperitoneal injection of endotoxin (10 microg per animal). Five days later, animals which underwent open surgery, laparoscopy with air sufflation or received an endotoxin injection displayed increased lung metastasis compared to anaesthetic controls. These increases in metastatic tumour growth were reflected in increased tumour cell proliferation and decreased apoptosis within lung metastases. Circulating levels of the angiogenic cytokine, vascular endothelial growth factor (VEGF), were also elevated in these groups and correlated with increased plasma levels of endotoxin. Endotoxin treatment for 18 h (>10 ng ml(-1)) directly up-regulated VEGF production by the 4T1 tumour cells in vitro. Metastatic tumour growth in mice undergoing carbon dioxide laparoscopy, where air is excluded, was similar to anaesthetic controls. These data indicate that endotoxin introduced during surgery is associated with the enhanced growth of metastases following surgical trauma, by altering the critical balances governing cellular growth and angiogenesis.

Local and systemic effects of intraoperative whole-colon washout with 5 per cent povidone-iodine

BACKGROUND

Segmental intraluminal instillation of several tumoricidal agents including povidone-iodine has been advocated to prevent anastomotic recurrence after colonic resection for colorectal cancer. The local and systemic effects of on-table whole-colon washout using 5 per cent povidone-iodine were assessed in patients undergoing elective surgery for colorectal cancer.

METHODS

The local effect of 5 per cent povidone-iodine on the colonic mucosa and the effect of colonic mucosal damage by povidone-iodine on tumour take was first investigated in Fischer 344 rats. In 12 euthyroid non-allergic patients, on-table whole-colon lavage via the appendix was performed. Systemic (thyroid function) and local (mucosal damage assessed by repeat biopsies) effects were studied, as well as the in vitro tumoricidal effect of the final anal effluent on tumour cell suspensions.

RESULTS

After 30 min of contact with povidone-iodine the rat colonic mucosa was severely injured, with detachment of the epithelial cell layer. Povidone-iodine-induced 'colitis' did not result in tumour development after inoculation of 10(6) Mtln3 carcinoma cells in ten rats. Epithelial desquamation was also observed, in all but one patient, 1 and 4 h after colonic lavage. However, epithelial restitution started within 1 day and no abnormality was revealed after 3-7 days. Urinary iodine excretion increased markedly and was not within normal values after 1 week. Levels of thyroid hormones decreased significantly but became normal within 1 week. The anal effluent containing povidone-iodine was found to be tumoricidal in vitro on a human colonic carcinoma cell line and on a tumour cell suspension produced from the patient's tumour.

CONCLUSION

On-table whole-colon washout using 5 per cent povidone-iodine seems clinically feasible. This technique deserves further study as a substitute for preoperative bowel preparation and may help to prevent recurrent cancer due to implantation of viable exfoliated tumour cells.

Significance of angiogenesis in cancer therapy

BACKGROUND

For most solid tumours, surgery remains the most effective primary treatment. Despite apparently curative resection, significant numbers of patients develop secondary disease due to growth of undetected micrometastases. The ability of a tumour to metastasize is related to the degree of angiogenesis it induces. In addition, micrometastases rely on new vessel formation to provide the nutrients necessary for growth. A better understanding of how tumours acquire their blood supply may lead to more effective adjuvant therapies and improve survival following surgery.

METHODS

A systematic review of the literature on angiogenesis between 1971 and 1997 was performed using the Medline database to ascertain current thinking on angiogenesis and its relevance in oncological surgery.

RESULTS

Angiogenesis is a physiological process subject to autocrine and paracrine regulation which has the potential to become abnormal and play a part in a number of pathological states, including cancer. Increased angiogenic stimuli in the perioperative period, associated with concomitant reduction in tumour-derived antiangiogenic factors following resection of a primary tumour, result in a permissive environment which allows micrometastases to grow.

CONCLUSION

Recognition of the role of angiogenesis in metastatic tumour growth represents a significant development in our understanding of tumour biology. The development of antiangiogenic agents offers new promise in the treatment of malignancy. Such agents may prevent or control the development and growth of primary and metastatic tumours.

Laparoscopic staging of bladder tumor: concerns about port site metastases

Since the first laparoscopic pelvic lymph node dissection (LPLND) was performed for prostate cancer, only one case of port site metastasis has been reported, an incidence of 0.1%. On the other hand, three cases of port site metastasis have been reported after laparoscopic staging of transitional-cell carcinoma (TCC) of the bladder, a reported incidence of almost 4%. Herein, we review the circumstances of these three cases and address the potential risk factors and possible preventive measures regarding LPLND and port site metastasis in patients with TCC of the bladder.

Anastomotic recurrence after curative resection of a transverse colon carcinoma: a case report

We report a case of anastomotic recurrence after curative surgery for transverse colon cancer in a 53-year-old man. The recurrence was first detected as a submucosal tumor 1.3 cm in diameter, located on the suture line, during an annual follow-up barium enema and colonoscopy. A repeat examination 3 months later showed the lesion to be a typical colon cancer, 2.5 cm in size, with a large ulcerated area. Right hemicolectomy was performed with curative intent. Anastomotic recurrence is much rarer after colonic resection than after anterior resection. This was the first time that we had detected a recurrent lesion as a submucosal tumor during annual follow-up examination.

Port-site recurrences following laparoscopic operations for gynaecological malignancies

OBJECTIVE

To determine the frequency of port-site recurrences following laparoscopic surgical treatment of gynaecological malignancies metastatic at the time of surgery.

DESIGN

Retrospective review of metastatic primary and recurrent gynaecological malignancies.

RESULTS

Twenty-five women were studied. Twenty-four had metastatic disease at the time of laparoscopic surgery, 22 in association with a primary malignancy (cervix: n = 12, ovary: n = 7, endometrium: n = 3), and two in association with recurrent ovarian cancer; all received pelvic or extended field radiation or chemotherapy after surgery. One woman with Stage IIIC ovarian cancer, disease-free at the completion of neoadjuvant chemotherapy following laparotomy by a general surgeon, was included; she developed scalene node metastases 18 months after definitive laparoscopic surgery. Seventy-one 5 mm trocars and fifty 10 mm trocars (total n = 121) were used for surgery; thirty-one 10 mm trocar sites and forty-four 5 mm sites (total n = 75) received post-operative treatment with chemotherapy (n = 49) or radiation (n = 26). Four women (16%) developed recurrences in association with endometrial (n = 2) and cervical (n = 2) cancer at six trocar sites. All recurrences were associated with abdominopelvic and/or distant metastases, and all occurred at untreated 5 mm trocar sites. The difference in recurrence rates between 5 mm and 10 mm trocar sites (chi(2) = 6; P < 0.025), and between treated and untreated trocars (chi(2) = 5; P < 0.05) were both statistically significant (McNemar's test), but the effects of treatment and trocar size on the port-site recurrence rate were confounded.

CONCLUSIONS

Port-site recurrences are local manifestations of disseminated disease that result from the enhancement of tumour growth characteristic of healing tissues and can be prevented by appropriate post-operative therapy.

Minimally invasive surgery for colorectal cancer. Initial follow-up

OBJECTIVE

An analysis was performed to evaluate early patterns of recurrence and survival in patients undergoing laparoscopic-assisted colectomies for primary colorectal cancer. Thirty-nine patients are available with a minimum of 24 months postoperative follow-up.

SUMMARY BACKGROUND DATA

The techniques and expected surgical outcomes for patients undergoing laparoscopically assisted colectomies are slowly being defined as these procedures become more common and more widely available. One of the areas of greatest concern is the use of laparoscopic-assisted colectomy for the surgical treatment of patients with primary colorectal cancer. There are anecdotal reports in the literature describing both port site recurrence and wound recurrence in patients undergoing laparoscopic-assisted colectomies for colorectal cancer. This raises concerns about whether these recurrences are more common in patients undergoing laparoscopic procedures and whether overall survival is compromised. Wound recurrences and laparoscopic port site recurrences have been described with numerous other intra-abdominal tumors, but the precise incidence remains unknown. The authors reviewed data from 39 patients to determine early patterns of recurrence and overall survival.

METHODS

Two-hundred thirty-eight laparoscopic-assisted colectomies were performed by the Norfolk Surgical Group between June 1992 and September 1995. Thirty-nine of the patients who underwent resection for colorectal cancer between June 1992 and September 1993 currently are available for at least a 2-year follow-up. Preoperative evaluation included physical examination, liver function studies, carcinoembryonic antigen, chest x-ray, computed tomography scans, and endoscopies with biopsy. Postoperative follow-up data consisted of physical examination, liver function tests, CEA, chest X-ray, computed tomography scan of the abdomen, and endoscopy of the colon. No patients have been lost to follow-up. Survival rates and patterns of recurrence were compared between node-negative and node-positive patients and compared with conventional data after open surgery.

RESULTS

There were 22 men and 17 women ranging in age from 33 to 89 years. Mean follow-up was 30 months, with a range of 24 to 40 months. There were three patients with recurrence and nine deaths. Recurrence and tumor-related death rates, respectively, for each Dukes' stage were 0/1 and 0/1 for stage A, 0/7 and 0/7 for stage B-1, 1/16 and 2/16 for stage B-2, 0/1 and 0/1 for stage C-1, and 2/8 and 1/8 for Stage C-2. All six patients with Dukes' stage D disease died of metastatic colorectal cancer within 4 to 14 months of surgery. There were two patients with anastomotic recurrence. No unusual patterns of recurrent disease were noted, and there were no wound or port site recurrences.

CONCLUSIONS

In this group of patients undergoing laparoscopic-assisted colectomies for primary colorectal malignancy, no adverse patterns of recurrence or decreased survival has been noted at 2-year follow-up when compared with standard open colorectal cancer surgery statistics. Prospective randomized studies with long-term follow-up will be required to better define the potential benefits and adverse effects of laparoscopic surgery for colorectal malignancy.

Impact of pneumoperitoneum on trocar site implantation of colon cancer in hamster model

BACKGROUND

Numerous anecdotal reports have documented the spread of colon cancer to trocar sites after laparoscopic-assisted colectomy. We hypothesized that the pneumoperitoneum of laparoscopy potentiated tumor adherence to trocar sites.

PURPOSE

This study was designed to determine the effect of CO2 pneumoperitoneum on the rate of tumor implantation at trocar sites.

METHODS

Viable GW-39 human colon cancer cells were injected into the abdominal cavity of hamsters (2 x 10(6) cells/hamster). A midline laparotomy, insertion of four 5-mm trocars, injection of viable cells into the mesentery of the cecum, and free peritoneal cavity was performed in two groups: one control group (41) who did not receive a pneumoperitoneum and a comparison group (50) who underwent pneumoperitoneum for ten minutes at an insufflation pressure of 10 mmHg. Animals were killed at six weeks, and hematoxylin and eosin-stained sections of trocar wounds, midline wound, small intestine, cecum, liver, and lung were examined by a veterinary pathologist, who was blinded to operation.

RESULTS

Pneumoperitoneum increased tumor implantation in the cecal mesentery and the midline incision (P < 0.05) but did not effect recurrence in the liver, lung, or jejunum. Trocar site implantation tripled with the addition of pneumoperitoneum increased implantation of pneumoperitoneum (26 vs. 75 percent) (P < 0.0001).

CONCLUSION

Pneumoperitoneum increased implantation of free intra-abdominal cancer cells at wound sites on the abdominal wall or within the abdominal cavity in this animal model. The use of pneumoperitoneum during laparoscopy in patients with colon cancer should only be performed in a protocol setting to evaluate the effect of pneumoperitoneum on the treatment of cancer.

Cancer recurrence following laparoscopic colectomy. Report of two patients treated with heated intraperitoneal chemotherapy

PURPOSE

Use of laparoscopic techniques for resection of colon and rectal cancer has raised considerable controversy. There is increasing concern that wound recurrence and peritoneal dissemination may represent a potentially fatal complication of this technique.

METHODS

The surgical literature was reviewed, and clinical course of two patients is presented.

RESULTS

Our two patients had tumor recurrence in the laparoscopy port sites within one year after laparoscopic assisted colectomy for Dukes B adenocarcinoma of the colon. At laparotomy, diffuse peritoneal carcinomatosis without lymph node or liver metastases were found in both patients. They were treated by surgical resection of recurrent disease combined with heated intraoperative intraperitoneal mitomycin C chemotherapy and five days of early postoperative intraperitoneal 5-fluorouracil. These patients are clinically free of disease at 1.5 years after treatment of peritoneal implants.

CONCLUSIONS

Cancer recurrence in abdominal wall incisions after laparoscopic colectomy has been reported in an increasing number of patients. It is possible that this technique should be abandoned. Cytoreductive surgery combined with intraperitoneal chemotherapy may represent the most adequate treatment of recurrent cancer that occurs following laparoscopic colectomy.

Epidermal growth factor-induced protection of tumour cell susceptibility to cytolysis

Using radiobinding, transfection and colorimetric assays, the biological significance of epidermal growth factor (EGF) and its receptor on established human tumour cell lines was investigated. The intensity of class I major histocompatibility antigen (MHC) and EGF receptor (EGFR) expression on 20 tumour cell lines was investigated and showed no direct correlation (coefficient of correlation r = 0.43 and P = 0.06). furthermore, transfection of the beta 2-microglobulin gene into a class I negative bladder tumour cell line, resulting in the re-expression of fully assembled cell surface class I antigens, did not result in alteration of EGFR expression. However, there was an inverse correlation between the intensity of EGFR expression and the stimulatory response of cells to exogenously added EGF. The per cent inhibitions of cell proliferation by EGF at 100 ng/ml for A431 (highest EGFR expressor) and Scaber (lowest EGFR expressor) were 37 and -7%, respectively. The results also showed that cell lines isolated from testis tumours positive for epithelial markers (using pan keratin antibody LP34 as an epithelial marker), expressed significantly lower EGFR levels than cell lines from bladder tumours. The expression of EGFR receptor was not modulated by interferons (IFN-alpha and -gamma and only a minor effect with IFN-beta) or active supernatant containing a mixture of cytokines. Whilst the pretreatment of tumour cells with IFNs resulted in a significant increase in the susceptibility of tumour cells to interleukin-2-activated peripheral blood mononuclear cells, EGF treatment resulted in their protection. Thus, the per cent killing at an effector:target ratio of 20:1 for untreated cells and EGF (100 ng/ml), IFN-alpha (1000 U/ml), -beta (2000 U/ml) and -gamma (100 U/ml) were 53%, 33% (P = 0.004), 64% (P = 0.004), 69% (P = 0.001) and 66% (P = 0.001), respectively. These results indicate the complex interactions between EGF and EGFR and their relevance in modifying tumour cell behaviour. The hypothesis that the resistance to cytolysis of tumour cells induced by EGF stimulation may be a factor in the accelerated tumour growth seen in patients after traumatic tissue damage is discussed.

Laparoscopic abdominoperineal excision of the rectum

In laparoscopic abdominoperineal resection of the rectum (LAP-AP) an abdominal incision is completely avoided as the tumor is delivered through the perineal incision. It is our belief that the view provided in the pelvis by laparoscopy is significantly better than at laparotomy and allows excellent anatomical definition and meticulous dissection. In this study we compared the adequacy of excision of the first 12 patients undergoing LAP-AP to the last 16 patients undergoing open abdominoperineal resection (OP-AP). In all patients the procedure was carried with curative intent for adenocarcinoma and the Dukes staging and Jass score's were similar in both groups. [table: see text] The data demonstrate similar nodal harvest in both groups as well as extent of radial excision. However, two patients in the open group had microscopic radial margin involvement despite being microscopically clear at surgery. We conclude that although long-term follow-up is required to address the issue of local cancer recurrence, laparoscopic rectal dissection appears as good as open surgery and may allow a more precise assessment of excision margins.

Laparoscopic colonic surgery

Laparoscopic surgical techniques have recently entered the field of colorectal surgery. Because the laparoscopic approach has revolutionized biliary surgery, it is hoped that similar advances will be possible in the more elderly population with colorectal disease. Early experience suggests that such advances have not been achieved and there is concern about developing minimal access surgical techniques in the face of potentially curable cancer. This article reviews the current state of knowledge based on published series; however, the current lack of controlled data in patients with extended follow-up makes this area highly controversial. Suggestions regarding the future of laparoscopic surgery are made and include the establishment of a national register and the development of controlled randomized trials.

Abdominal wall metastases following laparoscopy

Only 18 cases of recurrence at the sites of cannula insertion after laparoscopy have been reported in the literature, ten of them in the past year. The period between laparoscopic surgery and presentation of wound metastasis varies widely, from 7 days to 10 months; the lesions are typically hard, craggy and painful. The most likely mechanism is direct implantation of viable exfoliated tumour cells but three aspects specific to laparoscopy may also be important. First, there may be increased exfoliation of tumour cells following manipulation by laparoscopic instruments of an unsuspected malignancy. Second, there may be repeated close contact between tumour-laden instruments and the port. Third, the passage of resected tissue through a small incision may coat the wound with potentially malignant cells.

Paracrine growth regulation of human colon carcinoma organ-specific metastasis

The process of cancer metastasis consists of a series of steps resulting in the spread of malignant cells beyond the site of origin and formation of metastases in distant organs. The outcome of this nonrandom process depends, in part, on the interaction of unique tumor cells with a compatible organ microenvironment. The molecular basis of the intrinsic capacity of distinct malignant cells to colonize specific organs and the degree to which host factors influence this process is under intense investigation. Biological analyses of human colon carcinoma tumors obtained from surgical specimens and implanted orthotopically into athymic nude mice revealed that these tumors are heterogeneous for metastatic properties. Moreover, recent evidence using this model suggest that whereas nonmetastatic and highly metastatic cells can grow at local sites, growth in the secondary liver-specific site was associated only with highly metastatic HCC cells. These cells also respond to mitogenic signals produced by damaged normal tissues, suggesting that physiological signals can be utilized by neoplastic cells. Molecular characterization of highly metastatic HCC cells selected in the nude mouse model as well as in situ mRNA hybridization of archival HCC surgical specimens for specific growth factor receptors correlated with the malignant cell's ability to respond to organ-specific growth factors. This article will focus on biological and molecular evidence supporting the hypothesis that organ-derived, paracrine growth factors regulate the site-specific growth of receptive malignant cells that possess the appropriate receptors.

Abdominal wall recurrence after laparoscopic-assisted colectomy for adenocarcinoma of the colon. Report of a case

PURPOSE

To report an unusual mode of colorectal carcinoma recurrence after laparoscopic-assisted right hemicolectomy.

METHODS

Retrospective case review.

RESULTS

Laparoscopic-assisted colectomy has been shown in a variety of settings to be safe and technically feasible. The question of its efficacy in treating colorectal carcinoma remains uncertain. We report a case of a 71-year-old male who presented with a trocar site abdominal wall recurrence 10 months after a laparoscopic-assisted right hemicolectomy. To our knowledge, this represents the first such reported case in the literature.

CONCLUSION

Questions surrounding the efficacy of laparoscopic colectomy in eradicating colorectal carcinoma support the need for rigorous prospective study of this new technique.

Significance of local recurrence after mastectomy for breast cancer

In a retrospective study 678 patients who underwent (modified) radical mastectomy between 1970 and 1986 were analysed. By comparing the groups of patients who experienced local recurrence, regional recurrence or distant metastasis during follow-up with patients who remained free of disease, we have tried to gain some insight into the significance of local recurrence. By looking at the prognostic factors and the disease-free period there is hardly any difference between the patients with either a local, regional or distant recurrence. Actuarial survival of patients with local recurrence is slightly better than the survival of patients with distant metastasis (P = 0.009). From our results and from the literature we conclude that an isolated local recurrence after mastectomy for breast cancer is, in most cases, a first manifestation of metastatic disease. Probably only a minority of the local recurrences is caused by tumour cells left behind in the operation field.