Oncologic results after multivisceral resection of clinical T4 tumors

Minimally invasive versus open multivisceral resection for rectal cancer clinically invading adjacent organs: a propensity score-matched analysis

BACKGROUND

Minimally invasive surgery (MIS), such as laparoscopic and robotic surgery for rectal cancer, is performed worldwide. However, limited information is available on the advantages of MIS over open surgery for multivisceral resection for cases clinically invading adjacent organs.

PATIENTS AND METHODS

This was a retrospective propensity score-matching study of consecutive clinical T4b rectal cancer patients who underwent curative intent surgery between 2006 and 2021 at the University of Tokyo Hospital.

RESULTS

Sixty-nine patients who underwent multivisceral resection were analyzed. Thirty-three patients underwent MIS (the MIS group), while 36 underwent open surgery (the open group). Twenty-three patients were matched to each group. Conversion was required in 2 patients who underwent MIS (8.7%). R0 resection was achieved in 87.0% and 91.3% of patients in the MIS and open groups, respectively. The MIS group had significantly less blood loss (170 vs. 1130 mL; p < 0.0001), fewer Clavien-Dindo grade ≥ 2 postoperative complications (30.4% vs. 65.2%; p = 0.0170), and a shorter postoperative hospital stay (20 vs. 26 days; p = 0.0269) than the open group. The 3-year cancer-specific survival rate, relapse-free survival rate, and cumulative incidence of local recurrence were 75.7, 35.9, and 13.9%, respectively, in the MIS group and 84.5, 45.4, and 27.1%, respectively, in the open group, which were not significantly different (p = 0.8462, 0.4344, and 0.2976, respectively).

CONCLUSION

MIS had several short-term advantages over open surgery, such as lower complication rates, faster recovery, and a shorter hospital stay, in rectal cancer patients who underwent multivisceral resection.

Multivisceral resection of advanced colon and rectal cancer: a prospective multicenter observational study with propensity score analysis of the morbidity, mortality, and survival

Objectives

In the surgical treatment of colorectal carcinoma (CRC), 1 in 10 patients has a peritumorous adhesion or tumor infiltration in the adjacent tissue or organs. Accordingly, multivisceral resection (MVR) must be performed in these patients. This prospective multicenter observational study aimed to analyze the possible differences between non-multivisceral resection (nMVR) and MVR in terms of early postoperative and long-term oncological treatment outcomes. We also aimed to determine the factors influencing overall survival.

Methods

The data of 25,321 patients from 364 hospitals who had undergone surgery for CRC (the Union for International Cancer Control stages I-III) during a defined period were evaluated. MVR was defined as (partial) resection of the tumor-bearing organ along with resection of the adherent and adjacent organs or tissues. In addition to the patients' personal, diagnosis (tumor findings), and therapy data, demographic data were also recorded and the early postoperative outcome was determined. Furthermore, the long-term survival of each patient was investigated, and a "matched-pair" analysis was performed.

Results

From 2008 to 2015, the MVR rates were 9.9 % (n=1,551) for colon cancer (colon CA) and 10.6 % (n=1,027) for rectal cancer (rectal CA). CRC was more common in men (colon CA: 53.4 %; rectal CA: 62.0 %) than in women; all MVR groups had high proportions of women (53.6 % vs. 55.2 %; pairs of values in previously mentioned order). Resection of another organ frequently occurred (75.6 % vs. 63.7 %). The MVR group had a high prevalence of intraoperative (5.8 %; 12.1 %) and postoperative surgical complications (30.8 % vs. 36.4 %; each p<0.001). Wound infections (colon CA: 7.1 %) and anastomotic insufficiencies (rectal CA: 8.3 %) frequently occurred after MVR. The morbidity rates of the MVR groups were also determined (43.7 % vs. 47.2 %). The hospital mortality rates were 4.9 % in the colon CA-related MVR group and 3.8 % in the rectal CA-related MVR group and were significantly increased compared with those of the nMVR group (both p<0.001). Results of the matched-pair analysis showed that the morbidity rates in both MVR groups (colon CA: 42.9 % vs. 34.3 %; rectal CA: 46.3 % vs. 37.2 %; each p<0.001) were significantly increased. The hospital lethality rate tended to increase in the colon CA-related MVR group (4.8 % vs. 3.7 %; p=0.084), while it significantly increased in the rectal CA-related MVR group (3.4 % vs. 3.0 %; p=0.005). Moreover, the 5-year (yr) overall survival rates were 53.9 % (nMVR: 69.5 %; p<0.001) in the colon CA group and 56.8 % (nMVR: 69.4 %; p<0.001) in the rectal CA group. Comparison of individual T stages (MVR vs. nMVR) showed no significant differences in the survival outcomes (p<0.05); however, according to the matched-pair analysis, a significant difference was observed in the survival outcomes of those with pT4 colon CA (40.6 % vs. 50.2 %; p=0.017). By contrast, the local recurrence rates after MVR were not significantly different (7.0 % vs. 5.8 %; both p>0.05). The risk factors common to both tumor types were advanced age (>79 yr), pT stage, sex, and morbidity (each hazard ratio: >1; p<0.05).

Conclusions

MVR allows curation by R0 resection with adequate long-term survival. For colon or rectal CA, MVR tended to be associated with reduced 5-year overall survival rates (significant only for pT4 colon CA based on the MPA results), as well as, with a significant increase in morbidity rates in both tumor entities. In the overall data, MVR was associated with significant increases in hospital lethality rates, as indicated by the matched-pair analysis (significant only for rectal CA).

En-bloc resection including SMV and duodenum in patient of locally advanced colon cancer

Tumor could directly invade or is adherent to other organs, but superior mesentery vein (SMV) and duodenum invasion are very rare. A 62-year-old woman was diagnosed with abdominal pain for several months. Multiple erythematous brownish skin patches and palpable mass were found at epigastric area. Computed tomography imaging showed focal wall thickening at the transverse colon that invaded to the rectus muscle and anterior abdominal wall. On exploration, we identified tumor invaded or was adherent to the duodenum and superior mesenteric vein and performed en-bloc resection. After surgery, the patient received chemotherapy and was followed up without any recurrence for 16 months. Adhesion and invasion of tumor to surrounding organs can be unexpectedly found during surgery. In our case, we found duodenum and SMV invasion and achieved R0 resection by SMV and duodenum resection, which could improve the patient's prognosis.

Is it possible to adopt the same oncological approach in urgent surgery for colon cancer?

BACKGROUND

Locoregional complications may occur in up to 30% of patients with colon cancer. As they are frequent events in the natural history of this disease, there should be a concern in offering an oncologically adequate surgical treatment to these patients.

AIM

To compare the oncological radicality of surgery for colon cancer between urgent and elective cases.

METHODS

One-hundred and eighty-nine consecutive patients with non-metastatic colon adenocarcinoma were studied over two years in a single institution, who underwent surgical resection as the first therapeutic approach, with 123 elective and 66 urgent cases. The assessment of oncological radicality was performed by analyzing the extension of the longitudinal margins of resection, the number of resected lymph nodes, and the percentage of surgeries with 12 or more resected lymph nodes. Other clinicopathological variables were compared between the two groups in terms of sex, age, tumor location, type of urgency, surgical access, staging, compromised lymph nodes rate, differentiation grade, angiolymphatic and perineural invasion, and early mortality.

RESULTS

There was no difference between the elective and urgency group concerning the longitudinal margin of resection (average of 6.1 in elective vs 7.3 cm in urgency, P = 0.144), number of resected lymph nodes (average of 17.7 in elective vs 16.6 in urgency, P = 0.355) and percentage of surgeries with 12 or more resected lymph nodes (75.6% in elective vs 77.3% in urgency, P = 0.798). It was observed that the percentage of patients aged 80 and over was higher in the urgency group (13.0% in elective vs 25.8% in urgency, P = 0.028), and the early mortality was 4.9% in elective vs 15.2% in urgency (P = 0.016, OR: 3.48, 95%CI: 1.21–10.06). Tumor location (P = 0.004), surgery performed (P = 0.016) and surgical access (P < 0.001) were also different between the two groups. There was no difference in other clinicopathological variables studied.

CONCLUSION

Oncological radicality of colon cancer surgery may be achieved in both emergency and elective procedures.

The impact of hospital volume on survival in patients with locally advanced colonic cancer

BACKGROUND

High hospital volume has been shown associated with improved survival in patients with several cancers. The aim of this nationwide cohort study was to investigate whether hospital volume affects survival in patients with locally advanced colonic cancer.

METHODS

All patients with non-metastatic locally advanced colonic cancer diagnosed between 2007 and 2017 in Sweden were included. Tertiles of annual hospital volume of locally advanced colonic cancer were analysed and 5-year overall and colonic cancer-specific survival were calculated with the Kaplan-Meier method. HRs comparing all-cause and colonic cancer-specific mortality rates were estimated using Cox models adjusted for potential confounders (age, sex, year of diagnosis, co-morbidity, elective/emergency resection, and university hospital) and mediators (preoperative multidisciplinary team assessment, neoadjuvant chemotherapy, radical resection, and surgical experience).

RESULTS

A total of 5241 patients were included with a mean follow-up of 2.7-2.8 years for low- and high-volume hospitals. The number of patients older than 79 years were 569 (32.3 per cent), 495 (29.9 per cent), and 482 (26.4 per cent) for low-, medium- and high-volume hospitals respectively. The 3-year overall survival was 68 per cent, 60 per cent and 58 per cent for high-, medium- and low-volume hospitals, respectively (P < 0.001 from log rank test). High volume hospitals were associated with reduced all-cause and colon cancer-specific mortality after adjustments for potential confounders (HR 0.76, 95 per cent CI 0.62 to 0.93 and HR 0.73, 95 per cent CI 0.59 to 0.91, respectively). The effect remained after inclusion of potential mediators.

CONCLUSIONS

High hospital volume is associated with reduced mortality in patients with locally advanced colonic cancer.

Surgery for T4 Colorectal Cancer in Older Patients: Determinants of Outcomes

Background: This study aimed to compare the outcomes of older and younger patients with T4 colorectal cancer (CRC) treated with surgery. Methods: Consecutive patients with T4 CRC treated surgically at Henri Mondor Hospital between 2008 and 2016 were retrospectively analyzed in age subgroups (1) 50−69 years and (2) ≥70 years for overall and relative survival. The multivariable analyses were adjusted for adjusted for age, margin status, lymph node involvement, CEA level, postoperative complications (POC), synchronous metastases, and type of surgery. Results: Of 106 patients with T4 CRC, 57 patients (53.8%) were 70 years or older. The baseline characteristics were generally balanced between the two age groups. Older patients underwent adjuvant therapy less commonly (42.9 vs. 57.1%; p = 0.006) and had a longer delay between surgery and chemotherapy (median 40 vs. 34 days; p < 0.001). A higher trend for POC was reported among the older patients but did not impact the survival outcomes. After adjusting for confounding factors, the overall survival was shorter among the older patients (HR = 3.322, 95% CI 1.49−7.39), but relative survival was not statistically correlated to the age group (HR = 0.873, 95% CI 0.383−1.992). Conclusions: Older patients with CRC were more prone to severe POC, but age did not impact the relative survival of patients with T4 colorectal cancer. Older patients should not be denied surgery based on age alone.

The impact of multivisceral liver resection on short- and long-term outcomes of patients with colorectal liver metastasis: A systematic review and meta-analysis

The impact of Multivisceral Liver Resection (MLR) on the outcome of patients with Colorectal Liver Metastasis (CRLM) is unclear. The present systematic review aimed to compare patients with CRLM who underwent MLR versus standard hepatectomy regarding short- and long-term outcomes. MLR is a feasible procedure but has a higher risk of major complications. MLR did not negatively affect long-term survival, suggesting that an extended resection is an option for potentially curative treatment for selected patients with CRLM.

Rate of dissemination and prognosis in early and advanced stage colorectal cancer based on microsatellite instability status: systematic review and meta-analysis

INTRODUCTION

For the past two decades, microsatellite instability (MSI) has been reported as a robust clinical biomarker associated with survival advantage attributed to its immunogenicity. However, MSI is also associated with high-risk adverse pathological features (poorly differentiated, mucinous, signet cell, higher grade) and exhibits a double-edged sword phenomenon. We performed a systematic review and meta-analysis to evaluate the rate of dissemination and the prognosis of early and advanced stage colorectal cancer based on MSI status.

METHODS

A systematic literature search of original studies was performed on Ovid searching MEDLINE, Embase, Cochrane Database of Systematic Reviews, American College of Physicians ACP Journal Club, Database of Abstracts of Reviews of Effects DARE, Clinical Trials databases from inception of database to June 2019. Colorectal cancer, microsatellite instability, genomic instability and DNA mismatch repair were used as key words or MeSH terms. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was followed. Data were pooled using a random-effects model with odds ratio (OR) as the effect size. Statistical analysis was performed using RevMan ver 5.3 Cochrane Collaboration.

RESULTS

From 5288 studies, 136 met the inclusion criteria (n = 92,035; MSI-H 11,746 (13%)). Overall, MSI-H was associated with improved OS (OR, 0.81; 95% CI 0.73-0.90), DFS (OR, 0.73; 95% CI 0.66-0.81) and DSS (OR, 0.69; 95% CI 0.52-0.90). Importantly, MSI-H had a protective effect against dissemination with a significantly lower rate of lymph node and distant metastases. By stage, the protective effect of MSI-H in terms of OS and DFS was observed clearly in stage II and stage III. Survival in stage I CRC was excellent irrespective of MSI status. In stage IV CRC, without immunotherapy, MSI-H was not associated with any survival benefit.

CONCLUSIONS

MSI-H CRC was associated with an overall survival benefit with a lower rate of dissemination. Survival benefit was clearly evident in both stage II and III CRC, but MSI-H was neither a robust prognostic marker in stage I nor stage IV CRC without immunotherapy.

Feasibility and Outcomes of Multivisceral Resection in Locally Advanced Colorectal Cancer: Experience of a Tertiary Cancer Center in North-East India

Purpose

Locally advanced colorectal cancer may require an en bloc resection of surrounding organs or structures to achieve complete tumor removal. This decision must weigh the risk of complications of multivisceral resection against the potential survival benefit. The purpose of this study is to review a single-center experience of feasibility of en bloc multivisceral resections for locally advanced colorectal carcinoma and to examine the effect of surgical experience on immediate outcome and rate of R0 resections.

Methods

This is a study of 27 patients who underwent multivisceral resection for locally advanced colorectal carcinoma which was performed at our institute from January 2016 to December 2019. Among the 27 patients aged between 21 and 76 years (mean age, 48.67±7.3 years), 13 were males and 14 were females. Overall 18 patients had primary colon carcinoma and 9 had primary rectal carcinoma. All rectal cancer patients received neoadjuvant chemoradiation. All patients underwent surgery with curative intent. All patients underwent open surgery of which 66.7% underwent colectomy, 14.8% underwent anterior resection, 11.1% underwent Miles procedure, and 7.4% underwent pelvic exenteration.

Results

The mean operative time was 268.14±72.2 minutes and the median amount of blood units transfused was 2.07 units. The mean hospital stay was 13.67±3.4 days. Histologically, 44.4% of patients had well-differentiated adenocarcinoma and 55.6% had moderately differentiated adenocarcinoma. The final histopathological examinatio n revealed malignant infiltration of the adjacent organs in 19/27 patients (70.4%). Pathological complete response was seen in 2 patients. R0 resection rate achieved was 96.3%. Lymph node metastasis was seen in 66.7% of patients with colon cancer and 11.1% with rectal cancer with overall mean number of harvested lymph nodes being 12.44±3.01. Postoperative complications were identified in 7 patients (25.9%), while mortality was seen in 2 (7.4%).

Conclusion

Multivisceral resection for advanced colorectal cancer invading into the adjacent organ may be performed with acceptable morbidity and mortality.

Preoperative multidisciplinary team assessment is associated with improved survival in patients with locally advanced colon cancer; a nationwide cohort study in 3157 patients

INTRODUCTION

Multidisciplinary team (MDT) assessment is associated with improved survival in locally advanced rectal cancer, but the effect of an MDT assessment on survival in locally advanced colon cancer has not been reported. The aim of this national population-based cohort study was to establish if preoperative MDT assessment affects prognosis in patients with primary locally advanced colon cancer.

MATERIAL AND METHODS

All patients in Sweden with locally advanced colon cancer, without metastatic disease, who underwent an elective colon resection between 2010 and 2017 were identified through the Swedish Colorectal Cancer Registry (SCRCR), and the cohort was linked to national registers. Data on patient characteristics, preoperative staging, surgical procedures, recurrence and survival were collected from SCRCR. The association between MDT assessment and colon cancer-specific survival was evaluated using Kaplan-Meier survival curves and Cox proportional hazards models. The multivariable analysis was adjusted for sex, age, ASA grade, CCI, time period, pN, region and preoperative MDT.

RESULTS

MDT assessment was performed in 2663 patients (84.4%) of 3157 eligible patients. The 3-year colon cancer-specific survival was higher following MDT, compared with no MDT assessment (80% versus 68%). MDT assessment was independently associated with reduced colon cancer-specific mortality (HR 0.70, 0.57-0.84 95% CI).

CONCLUSION

Preoperative MDT assessment is associated with an improved long-term survival in patients with locally advanced colon cancer and should be mandatory in patients with suspected locally advanced colon cancer.

Laparoscopic resection of a metachronous secondary lymph node metastasis in the mesentery of the ileum after surgery for sigmoid colon cancer with ileum invasion: a case report

Background

Extended excision of the permeation organ neighborhood is often performed in locally invasive colon cancer, and it is reported to have a survival benefit. In addition, some cases of secondary lymph node metastases in a permeation organ were reported. However, they are reports of synchronous secondary lymph node metastases, not metachronous secondary lymph node metastases. To the best of our knowledge, there are no cases of metachronous secondary lymph node metastases after the resection of a primary colorectal cancer in PubMed.

Case presentation

The case was a 67-year-old man who underwent colonoscopy because of weight loss. Sigmoid colon cancer with all circumference-related stenosis was found by examination, and the patient was transferred to our hospital for the purpose of scrutiny and treatment. The small intestine ileus caused by the invasion of sigmoid colon cancer developed after the transfer. Laparoscopic high anterior resection and extended excision of small intestine segmental resection was performed after the intestinal tract decompression with a nasal ileus tube. Histopathological analysis revealed a pathological diagnosis of pT4b (ileal submucosal invasion) N0 (0/11) M0 f Stage II, tub2, ly1, v2, PN0. Although adjuvant chemotherapy with capecitabine after the operation was planned for half a year, treatment was suspended in the first course by the patient’s self-judgment. No recurrence was observed for a year after the operation, but metastasis recurrence in the para-aortic lymph node was found by a computed tomography (CT) one and a half years after the operation. 18 F-fluorodeoxyglucose (FDG) positron emission tomography revealed that FDG was accumulated only in the para-aortic lymph node. Laparoscopic metastasis lymphadenectomy was performed due to the diagnosis of metachronous metastasis to the para-aortic lymph node alone. Intraoperative findings revealed that lymph node metastasis occurred in the mesentery of the ileum. No adjuvant treatment was done after the secondary operation, and he is still alive with no recurrence 1 year and 9 months after the operation.

Conclusions

We report a rare case of a laparoscopic resection of a metachronous secondary lymph node metastasis in the mesentery of the ileum after surgery for sigmoid colon cancer with ileum invasion.

Outcomes of neoadjuvant chemoradiotherapy followed by radical resection for T4 colorectal cancer

BACKGROUND

Patients with clinical T4 colorectal cancer (CRC) have a poor prognosis because of compromised surgical margins. Neoadjuvant therapy may be effective in downstaging tumors, thereby rendering possible radical resection with clear margins.

AIM

To evaluate tumor downsizing and resection with clear margins in T4 CRC patients undergoing neoadjuvant concurrent chemoradiotherapy followed by surgery.

METHODS

This study retrospectively included 86 eligible patients with clinical T4 CRC who underwent neoadjuvant concurrent chemoradiotherapy followed by radical resection. Neoadjuvant therapy consisted of radiation therapy at a dose of 45-50.4 Gy and chemotherapy agents, either FOLFOX or capecitabine. A circumferential resection margin (CRM) of < 1 mm was considered to be a positive margin. We defined pathological complete response (pCR) as the absence of any malignant cells in a specimen, including the primary tumor and lymph nodes. A multivariate logistic regression model was used to identify independent predictive factors for pCR.

RESULTS

For 86 patients who underwent neoadjuvant chemoradiotherapy and surgery, the rate of pCR was 14%, and the R0 resection rate was 91.9%. Of the 61 patients with rectal cancer, 7 (11.5%) achieved pCR and 5 (8.2%) had positive CRMs. Of the 25 patients with colon cancer, 5 (20%) achieved pCR and 2 (8%) had positive CRMs. We observed that the FOLFOX regimen was an independent predictor of pCR (P = 0.046). After a median follow-up of 47 mo, the estimated 5-year overall survival (OS) and disease-free survival (DFS) rates were 70.8% and 61.4%, respectively. Multivariate analysis revealed that a tumor with a negative resection margin was associated with improved DFS (P = 0.014) and OS (P = 0.001). Patients who achieved pCR exhibited longer DFS (P = 0.042) and OS (P = 0.003) than those who did not.

CONCLUSION

Neoadjuvant concurrent chemoradiotherapy engenders favorable pCR and R0 resection rates among patients with T4 CRC. The R0 resection rate and pCR are independent prognostic factors for patients with T4 CRC.

Short-term and long-term outcomes of laparoscopic colectomy with multivisceral resection for surgical T4b colon cancer: Comparison with open colectomy

AIM

In response to the rising use of laparoscopic surgery, recent studies have shown that laparoscopic multivisceral resections for locally advanced colon cancer are safe, feasible, and provide acceptable oncological outcomes. However, the usefulness of laparoscopic multivisceral resection remains controversial. Here, we aimed to compare short-term and long-term outcomes between laparoscopic and open multivisceral resection approaches for treating locally advanced colon cancer.

METHODS

We retrospectively collected data on 1315 consecutive patients admitted to the National Hospital Organization, Osaka National Hospital, for surgical treatment of colorectal cancer between 2010 and 2017. We assessed invasiveness in terms of operating times, blood loss, and complications. Oncological outcomes included 5-year survival rates and recurrences.

RESULTS

We included 85 patients that underwent a colectomy with a multivisceral resection for locally advanced colon cancer; of these, 38 were treated with a laparoscopic approach and 47 were treated with an open approach. Compared to the open surgery group, the laparoscopic group had significantly less blood loss (median volume: 25 vs 140 mL, P <0.001), a lower complication rate (10.5% vs 29.8%, P = 0.036), and shorter hospital stays (12 vs 15 days, P = 0.028). After excluding patients with stage Ⅳ colon cancer, the groups showed similar pathologic outcomes and no significant differences in 5-year disease-free survival (73.9% vs 67.4%; P = 0.664) or 5-year overall survival (75.8% vs 67.7%; P = 0.695).

CONCLUSION

A laparoscopic approach for locally advanced colon cancer could be less invasive than an open approach without affecting oncological outcomes in selected patients.

Combined liver and multivisceral resections: A comparative analysis of short and long-term outcomes

BACKGROUND

En bloc liver and adjacent organs resections are technically demanding procedures. Few case series and nonmatched comparative studies reported the outcomes of multivisceral liver resections (MLRs).

OBJECTIVES

To compare the short and long-term outcomes of patients submitted MLRs with those submitted to isolated hepatectomies.

METHODS

From a prospective database, a case-matched 1:2 study was performed comparing MLRs and isolated hepatectomy. Additionally, a risk analysis was performed to evaluate the association between MLRs and perioperative morbidity, mortality, and long-term survival.

RESULTS

Fifty-three MLRs were compared with 106 matched controls. Patients undergoing MLRs had longer operative time (430 [320-525] vs 360 [270-440] minutes, P = .005); higher estimated blood loss (600 [400-800] vs 400 [100-600] mL; P = .011); longer hospital stay (8 [6-14] vs 7 [5-9] days; P = .003); and higher postoperative mortality (9.4% vs 1.9%, P = .042). Number of resected organs was not an independent prognostic factor for perioperative major complications (odds ratio [OR], 1 organ = 1.8 [0.54-6.05]; OR ≥ 2, organs = 4.0 [0.35-13.84]) or perioperative mortality (OR, 1, organ = 5.2 [0.91-29.51]; OR ≥ 2, organs = 6.5 [0.52-79.60]). No differences in overall (P = .771) and disease-free survival (P = .28) were observed.

CONCLUSION

MLRs are feasible with acceptable morbidity but relatively high perioperative mortality. MLRs did not negatively affect long-term outcomes.

Advanced colonic cancer with clinically suspected bladder invasion: Outcomes and prognosis from a multicentric study of 117 patients from the FRENCH research group

BACKGROUND

Bladder invasion by colon cancer is rare; however, its management is still controversial. Our objective was to report outcomes and identify risk factors for local recurrence in colon cancer with clinically suspected bladder invasion.

METHODS

We conducted a retrospective study in 23 centers in France. All patients who underwent colon surgery with bladder resection (2010-2017) were included. Metastatic and recurrent colon cancers were excluded.

RESULTS

One hundred and seventeen patients (men = 73) were included. Partial cystectomy occurred in 108 patients (92.3%), with a total cystectomy occurring in 9 patients (7.7%). Neoadjuvant treatment was given to 31 patients (26.5%). Major morbidity was 20.5%. R0 resection rates were 87.2%. Histologically confirmed bladder invasion was present in 47%. Thirty-four patients were pN+, while 60 patients (51.3%) received adjuvant chemotherapy. Mean follow-up was 33.8 months. Three-year overall survival and disease-free survival were 82.9% and 59.5%. Rates of local recurrence and distant recurrence were 14.5% and 18.8%, respectively; the local recurrences (11/17; 65%) were in the bladder, while 4 of these patients had a bladder recurrence despite not having histologically confirmed bladder invasion at the index surgery. The rate of bladder recurrence after histologic bladder invasion was 13% (7/55), while the rate of bladder recurrence without primary bladder invasion was 7% (4/62) (P = .343). Neoadjuvant therapy, type of cystectomy, and adjuvant therapy did not influence local recurrence (P > .445 each). R1 bladder resections, when compared with a R0 bladder resections, were associated with an increased rate of local recurrence (63% vs 10%; P < .0001).

CONCLUSION

Clinically suspected bladder invasion increases local recurrence even in the absence of histologically confirmed bladder invasion. Only complete resections with R0 margins decrease local recurrence. Careful, detailed postoperative surveillance is required, even without pathologic bladder invasion.

Post-operative and oncological 3-year follow-up outcomes in stage 2 colonic cancer in the emergency and elective setting: a cohort study

BACKGROUND

Stage 2 colonic cancer comprises a heterogeneous group of patients with a spectrum of disease, from invasion of the sub-serosa to tumour perforation into visceral peritoneum/adjacent organs. This study evaluates the post-operative outcomes and prognostic factors of patients with both emergency and elective presentations of stage 2 colonic cancer treated with curative intent.

METHODS

Retrospective analysis of a prospectively maintained database of adult patients (emergency and elective) who underwent curative surgery for stage 2 colonic cancer in a single tertiary referral centre between 2007 and 2016 was conducted. Multivariate analysis was performed to identify prognostic factors. Measured variables included demographics, complications, histology, disease-free survival and overall survival (OS).

RESULTS

A total of 428 patients with stage 2 colonic cancer received curative surgical resection, and negative resection margins were achieved in all cases: T3 group (stage 2A): 316 (73.8%); T4a group (stage 2B): 78 patients (18.2%); and T4b group (stage 2C): 34 (8%). There were 187 (45.7%) post-operative complications, 32 (7.5%) anastomotic leaks and eight (1.9%) 30-day mortalities. Eighty patients (19.3%) died during the follow-up. During the follow-up period, 45 patients developed recurrence (all distant). Multivariate analysis identified age >70 years, American Society of Anesthesiologists grades III-IV and male gender as factors associated with poor OS, while recurrence was higher in those aged over 70 years and with stages 2B-2C disease.

CONCLUSION

Surgical morbidity in patients with stage 2 colonic cancer who have undergone curative surgery is high. Older and more co-morbid patients have poorer OS. Stages 2B and 2C colon cancer patients have worse prognosis than those with stage 2A regarding recurrence. Future larger data sets are required to determine the role of transmural spread as a prognostic factor.

Significance of multivisceral resections in oncologic surgery: A systematic review of the literature

BACKGROUND

Multivisceral resections (MVR) are often necessary to reach clear resections margins but are associated with relevant morbidity and mortality. Factors associated with favorable oncologic outcomes and elevated morbidity rates are not clearly defined.

AIM

To systematically review the literature on oncologic long-term outcomes and morbidity and mortality in cancer surgery a systematic review of the literature was performed.

METHODS

PubMed was searched for relevant articles (published from 2000 to 2018). Retrieved abstracts were independently screened for relevance and data were extracted from selected studies by two researchers.

RESULTS

Included were 37 studies with 3112 patients receiving MVR for colorectal cancer (1095 for colon cancer, 1357 for rectal cancer, and in 660 patients origin was not specified). The most common resected organs were the small intestine, bladder and reproductive organs. Median postoperative morbidity rate was 37.9% (range: 7% to 76.6%) and median postoperative mortality rate was 1.3% (range: 0% to 10%). The median conversion rate for laparoscopic MVR was 7.9% (range: 4.5% to 33%). The median blood loss was lower after laparoscopic MVR compared to the open approach (60 mL vs 638 mL). Lymph-node harvest after laparoscopic MVR was comparable. Report on survival rates was heterogeneous, but the 5-year overall-survival rate ranged from 36.7% to 90%, being worst in recurrent rectal cancer patients with a median 5-year overall survival of 23%. R0 -resection, primary disease setting and no lymph-node or lymphovascular involvement were the strongest predictors for long-term survival. The presence of true malignant adhesions was not exclusively associated with poorer prognosis.

Included were 16 studies with 1.600 patients receiving MVR for gastric cancer. The rate of morbidity ranged from 11.8% to 59.8%, and the main postoperative complications were pancreatic fistulas and pancreatitis, anastomotic leakage, cardiopulmonary events and post-operative bleedings. Total mortality was between 0% and 13.6% with an R0 -resection achieved in 38.4% to 100% of patients. Patients after R0 resection had 5-year overall survival rates of 24.1% to 37.8%.

CONCLUSION

MVR provides, in a selected subset of patients, the possibility for good long-term results with acceptable morbidity rates. Unlikelihood of achieving R0 -status, lymphovascular- and lymph -node involvement, recurrent disease setting and the presence of metastatic disease should be regarded as relative contraindications for MVR.

Failure of 3 different methods and biopsy sites to diagnose a patient with invasive colorectal cancer: A case report

RATIONALE

Colorectal cancer is one of the most commonly diagnosed cancers worldwide, and the majority arise from neoplastic adenomatous polyps. Bladder involvement in colorectal cancer is uncommon and found in approximately 3% of the cases, most commonly in sigmoid and rectal tumors and the diagnosis is classically based on biopsies of affected tissues.

PATIENT CONCERNS

A 68-year-old male with no significant past medical history underwent diagnostic colonoscopy for abdominal distension and constipation with positive fecal occult blood test ordered by the primary care physician.

DIAGNOSIS

Colonoscopy showed a sigmoid mass with biopsy finding of tubulovillous adenoma. Laparoscopy was performed for sigmoid colonic resection, but as the mass was large, a diverting loop colostomy and multiple biopsies were performed revealing tubulovillous adenoma again. Postoperative workup revealed right hydronephrosis, and cystoscopy was performed confirming bladder wall invasion with biopsies showing benign bladder wall tissue with no evidence of dysplasia or malignancy. Furthermore, computed tomography (CT)-guided core-needle biopsies of the colonic mass were performed but revealed adenomatous colonic mucosa without evidence of carcinoma.

INTERVENTION

Definitive surgical en bloc excision of the tumor and anterior bladder wall was performed with urology team until grossly free margins were attained. Final pathology revealed well-differentiated mucinous adenocarcinoma arising from a preexisting tubulovillous adenoma with direct invasion of the bladder wall.

OUTCOMES

The patient's postoperative recovery was uneventful, and he was discharged 2 weeks postoperatively with planned adjuvant chemotherapy.

LESSONS

This case represents a classical presentation of invasive colorectal cancer. Perioperative workup, however, was confounded by failure of open, cystoscopic, and CT-guided biopsies to establish a tissue diagnosis for directed therapy. Upon literature review, evidence exists to support our approach to this unique dilemma.

Short- and Long-term Outcomes of Minimally Invasive Versus Open Multivisceral Resection for Locally Advanced Colorectal Cancer

BACKGROUND

Colorectal cancer invading the adjacent organs/structures is detected in 5% to 20% of all surgical interventions performed for the management of colorectal cancer.

OBJECTIVE

Our purpose is to verify the safety and feasibility of laparoscopic surgery for the treatment of locally advanced colorectal cancer invading the adjacent organs.

DESIGN

This is a retrospective study.

SETTINGS

The study was conducted at a single institution in Japan.

PATIENTS

We compared the morbidity, appropriate oncological resection, and disease-free survival of laparoscopic and open multivisceral resection in patients with colorectal carcinoma in the period between 2007 and 2015.

MAIN OUTCOME MEASURES

The primary outcome measures were curative resection rate, morbidity rate, and recurrence of laparoscopic and open multivisceral resection in patients with colorectal cancer.

RESULTS

Thirty-one patients received laparoscopic surgery, and 50 received open surgery. The amount of blood loss was smaller in the laparoscopic group than in the open group (60 vs 595 mL, p < 0.01). Curative surgery was performed in 46 patients of the open group (92.0%) and in 30 patients of the laparoscopic group (96.8%). Days until oral intake (5 vs 7 days, p < 0.01) and postoperative hospital stay (14 vs 19 days, p < 0.01) were shorter in the laparoscopic group. Overall morbidity was not different between the groups (22.5% vs 40.0%). Three-year disease-free survival rates were 62.7% in the open group and 56.7% in the laparoscopic group (p = 0.5776).

LIMITATION

This study was a retrospective small study conducted at a single institute.

CONCLUSION

Laparoscopic multivisceral resection may be a safe, less invasive alternative to open surgery, with less blood loss and shorter hospital stay, and was not inferior to open surgery based on long-term oncological end points. See Video Abstract at http://links.lww.com/DCR/A785.

Impact of postoperative complications on long-term survival following surgery for T4 colorectal cancer

BACKGROUND

Postoperative complications (POCs) after the resection of locally advanced colorectal cancer (CRC) may influence adjuvant treatment timing, outcomes, and survival. This study aimed to evaluate the impact of POCs on long-term outcomes in patients surgically treated for T4 CRC.

METHODS

All consecutive patients who underwent the resection of T4 CRC at a single centre from 2004 to 2013 were retrospectively analysed from a prospectively maintained database. POCs were assessed using the Clavien-Dindo classification. Patients who developed POCs were compared with those who did not in terms of recurrence-free survival (RFS) and overall survival (OS).

RESULTS

The study population comprised 106 patients, including 79 (74.5%) with synchronous distant metastases. Overall, 46 patients (43%) developed at least one POC during the hospital stay, and of those patients, 9 (20%) had severe complications (Clavien-Dindo ≥ grade III). POCs were not associated with OS (65% with POCs vs. 69% without POCs; p = 0.72) or RFS (58% with POCs vs. 70% without POCs; p = 0.37). Similarly, POCs did not affect OS or RFS in patients who had synchronous metastases at diagnosis compared with those who did not.

CONCLUSIONS

POCs do not affect the oncological course of patients subjected to the resection of T4 CRC, even in cases of synchronous metastases.

Management and Outcome After Multivisceral Resections in Patients with Locally Advanced Primary Colon Cancer

BACKGROUND

Locally advanced colon cancer invading surrounding organs or structures is challenging to surgeons and oncologists. Multivisceral resections with tumor removal en bloc with invaded tissues provide the best chance for cure.

OBJECTIVE

We aimed to assess the management and outcomes after multivisceral resections in patients with clinically infiltrative, locally advanced primary colon cancer.

DESIGN

This is a descriptive retrospective cohort study.

SETTINGS

A total of 121 consecutive patients with locally advanced primary colon cancer underwent en bloc multivisceral resections at a tertiary referral unit for colorectal cancer between 2007 and 2014.

MAIN OUTCOME MEASURES

Patient demographics, surgical details, histopathological findings, and outcomes were analyzed through registry data and reviews of patient files.

RESULTS

An R0 resection was achieved in 112 patients (92.6%), and an R1 resection was achieved in 9 patients (7.4%). Actual tumor cell infiltration in resected tissues was found in 77 patients (63.6%), and inflammation was found in 44 patients (36.4%). The estimated 5-year overall survival was 60.8% and 86.9%. Survival was significantly better after R0 than after R1 resections. After a median follow-up of 28 months, recurrent disease was diagnosed in 25 patients (20.7%). Female sex, low tumor stage, and adjuvant chemotherapy, but not tumor infiltration per se, were independently associated with better overall survival in a multivariate analysis.

LIMITATIONS

The main limitations of the study are the retrospective design and the fact that all patients were operated on at 1 institution by a small number of surgeons.

CONCLUSIONS

Patients with locally advanced colon cancer can be cured with an R0 resection. All involved surrounding tissues should be removed en bloc with the primary tumor. See Video Abstract at http://links.lww.com/DCR/A548.

Short- and Long-Term Outcomes of Laparoscopic Multivisceral Resection for Clinically Suspected T4 Colon Cancer

BACKGROUND

The use of laparoscopic surgery for colorectal cancer has become widespread recently. However, the safety and oncological outcomes of laparoscopic surgery for primary advanced colorectal cancer need extensive investigation. We analyzed the short- and long-term outcomes after laparoscopic multivisceral resection for primary colon cancer with suspected invasion of other organs at a single institution.

METHODS

Between January 2000 and December 2014, 118 patients underwent laparoscopic multivisceral resection for primary colon cancer invading or adhering to adjacent organs or structures; their short- and long-term outcomes were retrospectively evaluated.

RESULTS

The median operating time was 254 min (range 130-1051 min), and median blood loss was 48 ml (range 0-2777 ml). The overall conversion rate was 6.8%. The postoperative complication rate was 17.8%. The number of patients with R0 and R1 resection was 112 (94.9%) and 6 (5.1%), respectively. At a median follow-up period of 32 months (range 0-157 months), the local recurrence rate in patients who underwent R0 resection was 1.8%, while for R1 resection it was 66.7%. In multivariate analysis, R1 resection and LN metastases were found to be predictors of poor prognosis. The cancer-specific 5-year survival was 87% when R0 resection was achieved; within these, the 5-year survival rates for patients with stages II, III, and IV disease were 94, 81, and 40%, respectively.

CONCLUSIONS

Laparoscopic en bloc multivisceral resection for clinically suspected T4 colon cancer is a safe and feasible procedure for precisely selected patients, attaining satisfactory oncological outcomes when R0 resection is achieved.

Multivisceral resections for locally advanced colorectal cancer after preoperative treatment

Multivisceral resection for colorectal cancer invading into the adjacent organs may often be difficult and may involve serious complications. Preoperative therapy may facilitate resection with safe margins. Between August 2007 and July 2016, 23 patients with colorectal cancer invading into the adjacent organs treated with preoperative treatment (chemoradiotherpay, chemotherapy, radiotherapy) were retrospectively investigated. All 23 patients received surgery with curative intent. Four patients had distant metastases at the time of diagnosis. Two patients had distant metastasis after preoperative treatment. The mean operative time was 535.3±185.5 min and the median amount of blood loss was 1,050 ml. Histopathological examination revealed malignant infiltration of the adjacent organs in 14 patients (60.9%). R0 resection rate was 73.9%. Postoperative complications were identified in nine patients (39.1%) and a high incidence of infectious complications was observed. Patients with curative resection showed a significantly better survival than patients with R1 or R2 resection (P<0.01). Multivisceral resection for locally advanced colorectal cancer invading into the adjacent organ after preoperative treatment may be performed with acceptable morbidity and minimal mortality. R0 resection improves the prognosis of patients with locally advanced colorectal cancer invading into the adjacent organ after preoperative treatment.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Colon Cancer

The American Society of Colon and Rectal Surgeons is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines Committee is composed of society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than to dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient.

Prognostic factors affecting outcomes in multivisceral en bloc resection for colorectal cancer

OBJECTIVES:

This study sought to determine the clinical and pathological factors associated with perioperative morbidity, mortality and oncological outcomes after multivisceral en bloc resection in patients with colorectal cancer.

METHODS:

Between January 2009 and February 2014, 105 patients with primary colorectal cancer selected for multivisceral resection were identified from a prospective database. Clinical and pathological factors, perioperative morbidity and mortality and outcomes were obtained from medical records. Estimated local recurrence and overall survival were compared using the log-rank method, and Cox regression analysis was used to determine the independence of the studied parameters. ClinicalTrials.gov: NCT02859155.

RESULTS:

The median age of the patients was 60 (range 23-86) years, 66.7% were female, 80% of tumors were located in the rectum, 11.4% had stage-IV disease, and 54.3% received neoadjuvant chemoradiotherapy. The organs most frequently resected were ovaries and annexes (37%). Additionally, 30.5% of patients received abdominoperineal resection. Invasion of other organs was confirmed histologically in 53.5% of patients, and R0 resection was obtained in 72% of patients. The overall morbidity rate of patients in this study was 37.1%. Ureter resection and intraoperative blood transfusion were independently associated with an increased number of complications. The 30-day postoperative mortality rate was 1.9%. After 27 (range 5-57) months of follow-up, the mortality and local recurrence rates were 23% and 15%, respectively. Positive margins were associated with a higher recurrence rate. Positive margins, lymph node involvement, stage III/IV disease, and stage IV disease alone were associated with lower overall survival rates. On multivariate analysis, the only factor associated with reduced survival was lymph node involvement.

CONCLUSIONS:

Multivisceral en bloc resection for primary colorectal cancer can be performed with acceptable rates of morbidity and mortality and may lead to favorable oncological outcomes.

Secondary metastasis in the lymph node of the bowel invaded by colon cancer: a report of three cases

BACKGROUND

Secondary metastasis to regional lymph nodes for adjacent bowel invaded by colorectal cancers (CRCs) has not been extensively reviewed. We herein present three such cases.

CASE PRESENTATION

The first case is a cancer involving the cecum and sigmoid colon, and its primary site could not be determined even by pathological evaluation. Nodal involvement was revealed both in the mesocolon of the cecum and sigmoid. The second and third cases are a sigmoid colon cancer invading the jejunum and an ascending colon cancer invading the jejunum, respectively. These patients harbored secondary metastases to lymph nodes draining from the invaded small bowel segments. In spite of complete resection, all three patients metachronously developed liver metastases or recurrent disseminated nodules in the pelvis and subsequently died.

CONCLUSIONS

In cases of CRC invading another bowel segment, bowel resection with regional lymphadenectomy for both involved segments should be considered to achieve complete resection. However, the radical surgery did not necessarily provide a long-term survival.

Multivisceral resections for rectal cancers: short-term oncological and clinical outcomes from a tertiary-care center in India

BACKGROUND

Locally advanced rectal cancers (LARCs) involve one or more of the adjacent organs in upto 10-20% patients. The cause of the adhesions may be inflammatory or neoplastic, and the exact causes cannot be determined pre- or intra-operatively. To achieve complete resection, partial or total mesorectal excision (TME) en bloc with the involved organs is essential. The primary objective of this study is to determine short-term oncological and clinical outcomes in these patients undergoing multivisceral resections (MVRs).

METHODS

This is a retrospective review of a prospectively maintained database. Between 1 July 2013 and 31 May 2015, all patients undergoing MVRs for adenocarcinoma of the rectum were identified from this database. All patients who had en bloc resection of an adjacent organ or part of an adjacent organ were included. Those with unresectable metastatic disease after neoadjuvant therapy were excluded.

RESULTS

Fifty-four patients were included in the study. Median age of the patients was 43 years. Mucinous histology was detected in 29.6% patients, and signet ring cell adenocarcinoma was found in 24.1% patients. Neoadjuvant therapy was given in 83.4% patients. R0 resection was achieved in 87% patients. Five-year overall survival (OS) was 70% for the entire cohort of population.

CONCLUSIONS

In Indian subcontinent, MVRs in young patients with high proportion of signet ring cell adenocarcinomas based on magnetic resonance imaging (MRI) of response assessment (MRI 2) is associated with similar circumferential resection margin (CRM) involvement and similar adjacent organ involvement as the western patients who are older and surgery is being planned on MRI 1 (baseline pelvis). However, longer follow-up is needed to confirm noninferiority of oncological outcomes.

Multivisceral resection for advanced rectal cancer: outcomes and experience at a single institution

BACKGROUND

Multivisceral resection is often required in the treatment of locally advanced rectal cancers. Such resections are relatively rare and oncologic outcomes, especially when sphincter preservation is performed, are not fully demonstrated.

METHODS

A retrospective review was conducted of patients who underwent multivisceral resection for locally advanced rectal cancer with and without sphincter preservation.

RESULTS

Sixty-one patients underwent multivisceral resection for rectal cancer from 2005 to 2013 with a median follow-up of 27.8 months. Five-year overall and disease-free survival were 49.2% and 45.3%, respectively. Thirty-four patients (55.7%) had sphincter-sparing operations with primary coloanal anastomosis and temporary stoma. There was no significant difference in overall or disease-free survival, or recurrence with sphincter preservation compared with those with permanent stoma.

CONCLUSIONS

Multivisceral resection for locally advanced rectal cancer has acceptable oncologic and clinical outcomes. Sphincter preservation and subsequent reestablishment of gastrointestinal continuity does not impact oncologic outcomes and should be considered in many patients.