Ganglions et cancer du rectum

Laparoscopic resection for rectal adenocarcinoma

AIMS

Laparoscopic surgery for rectal cancer is still under discussion, but there is evidence that minimal access surgery can be feasible and safe also in this field. The aim of this study was to confirm that laparoscopic resection for rectal cancer can afford good results in terms of recurrence rate and survival.

PATIENTS AND METHODS

Since June 1998 through December 2007 as many as 252 patients underwent laparoscopic resection for rectal cancer. Laparoscopic anterior resection (LAR) was performed in 209 and laparoscopic abdominoperineal resection (LAPR) in 43. Neoadjuvant radiochemotherapy (nCRT) was administered in 48 patients with mid-low rectal cancer stage II and III with evidence of nodal involvement in preoperative work up.

RESULTS

Patients who received nCRT showed a significant longer duration of surgery compared to patients who did not (p=0.004). Conversion to laparotomy was needed in 24 cases, (21 LAR and three LAPR) but no patient receiving nCRT needed conversion. Postoperative surgical complications occurred in 38 patients, 20 of which were represented by anastomotic leak after LAR. Six patients died postoperatively, in half the cases for surgery related causes. Downstaging after nCRT was seen in 40 patients, and complete histological response was observed in six cases. The mean number of lymph nodes harvested was 12, also in patients receiving nCRT. The mean follow-up was 48+/-33 months (range 0.1-120.4), and 10 patients experienced local recurrence. Cumulative 5 year survival was 73.7%.

CONCLUSION

Laparoscopic resection for rectal cancer is feasible and safe, with morbidity and long-term results quite acceptable also in patients receiving neoadjuvant treatment.

[Management of superficial rectal cancers]

Superficial rectal cancers consist of Tis and T1 tumors as defined by the TNM classification system. Earlier detection of colorectal cancers through endoscopic screening should lead to an increase in the percentage of superficial cancers detected while still superficial; they may eventually represent more than a third of diagnosed rectal cancers. Endorectal ultrasound, ideally performed with a mini-probe, is the best pre-operative study to define the level of penetration into the rectal wall; depth of penetration and grade of differentiation are the major factors to be considered when contemplating local excision as an alternative to radical resection. Local excision can be performed endoscopically or by the classic transanal surgical approach. Each technique has pros and cons and the two are often complementary. Compared to the alternative of radical proctectomy, they have the decided advantages of zero mortality, minimal morbidity, and decreased expense. Pathologic examination of the resected specimen is the final determinant as to whether local resection is adequate therapy. When histologic prognostic factors are favorable (well-differentiated, absence of lymphatic or vascular invasion, superficial invasion of the submucosa (sm1), and clear resection margins), the risk of lymph node spread is negligible. When histologic prognostic factors are not favorable, a completion radical proctectomy should be performed.

No prognostic impact of isolated lymphovascular invasion after radical resection of rectal cancer--results of a multicenter observational study

BACKGROUND

The prognostic impact of isolated lymphovascular invasion (LVI) after radical resection of rectal cancer is controversially discussed. However, it could be relevant to decide for an adjuvant treatment.

AIM

The aim of the analysis was, based on the data of an observational study, to determine the prognostic relevance of the isolated LVI.

MATERIALS AND METHODS

Patients after radical resection of rectal cancer with no hemangioinvasion were subdivided in three groups: I-no LVI, no lymph node metastases (LNM); II-positive LVI, no LNM; III-positive LNM. Five-year local recurrence rate, distant metastases-free and disease-free survival were determined uni- and multivariate.

RESULTS

Patients, n = 846, were studied (I, n = 471; II, n = 75; III, n = 300). The univariate comparison between the groups revealed the following 5-year results: local recurrence rate: 9.4 vs 10.0 vs 14.0%; distant metastases-free survival: 84.1 vs 82.5 vs 49.3%; disease-free survival: 83.2 vs 80.7 vs 45.5%. The differences between groups I and III were significant, but not between groups I and II. The determined higher disease-free survival rate in group II vs group III was significant (P = 0.041), but the differences in local recurrence rate and rate of distant metastases did not reach statistical significance. The multivariate analysis revealed no impact of the isolated LVI on the oncological outcome.

CONCLUSION

The isolated LVI has no independent prognostic impact on the local recurrence rate and long-term survival after radical resection of rectal cancer. Based on this finding, no indication for an adjuvant treatment in these patients can be derived.

Introducción de la laparoscopia en el tratamiento del cáncer de recto en una unidad de coloproctología

INTRODUCTION

The application of the laparoscopic approach to the treatment of rectal cancer is controversial. The aim of the present study was to evaluate whether the introduction of this technique in a coloproctology unit modified the quality of rectal cancer surgery.

MATERIAL AND METHOD

We performed a prospective, nonrandomized study of all patients with rectal cancer who underwent surgery with curative intent in 2003 and 2004. Patients with stage T4 tumors were excluded. Of the 59 patients included, 33 underwent laparoscopic surgery and 26 underwent open surgery. A series of intraoperative and postoperative variables and characteristics of the surgical specimen were compared between the two groups.

RESULTS

No differences were found between the two groups in the type of intervention performed or in the rate of sphincter preservation. Overall morbidity was 39% in the laparoscopic group and 34% in the open surgery group (NS). Anastomotic dehiscence was 9.5% and 5.8% respectively (NS). The length of hospital stay was similar in both groups. The distal margin was adequate in all patients. The circumferential resection margin was positive (< 1 mm) in 10.7% of patients in the laparoscopic group who underwent total mesorectal excision and in 13.6% of those in the open surgery group (NS). The mean number of isolated nodes was 12.5 in the laparoscopic group and 15.5 in the open surgery group (NS).

CONCLUSION

The introduction of the laparoscopic approach in the treatment of rectal cancer in our unit has not lowered surgical quality, as measured by clinical and histopathological variables.

Radio-guided sentinel node detection during the surgical treatment of rectal cancer

OBJECTIVE

The detection of sentinel nodes is performed in various types of malignant disease. The aim of this study was to evaluate the results of the radiodetection of sentinel nodes, based on the use of Tc-colloid, during the surgical treatment of rectal cancer.

METHODS

In 2003-2004, 42 patients (24 males and 18 females; average ages of 62.4 and 67 years, respectively) were examined during rectal carcinoma surgical procedures. Miles abdominoperineal rectal resection was performed in nine cases; 33 patients underwent low anterior rectum resection by total mesorectal excision. On the day of the operation, a transanal submucosal infiltration of colloid labelled with radioactive 99mTc was performed; infiltration was performed strictly peritumorally. After the operation, radiodetection of the surgical specimens (using a hand-held gamma probe) was performed. The areas of higher radioactivity were marked. The specimens were then examined by a histopathologist. The nodes found closest to the marked areas were considered to be 'sentinel nodes'. The results of scintigraphy and postoperative radiodetection were checked by histological examination. All the discovered lymph nodes were examined by haematoxylin and eosin staining; when this was negative, immunohistochemical examination with cytokeratin was used for the sentinel nodes.

RESULTS

In 36 of the 42 patients, the data obtained by scintigraphy and radiodetection were in agreement with histopathological proof of a sentinel node. The sensitivity of the method in this group of patients was 86% (95% confidence limits: 70.75-94.05).

CONCLUSIONS

The scintigraphic method of detection of sentinel nodes in total mesorectal excision is not therapeutic, but diagnostic, and demonstrates a high level of reliability. It can be used to indicate the nodes that should be examined to detect the presence of possible micrometastases immunohistochemically. However, this method cannot be used for all detected nodes as it is very demanding. In the evaluated group of patients, there were no intraoperative or postoperative complications caused by this diagnostic method.