Multimodality management of locally recurrent colorectal cancer

Negative prognostic factors in colorectal carcinoma: An analysis of 448 patients

BACKGROUND AND AIMS

Colorectal carcinoma (CRC) is the most frequent malignancy of the gastrointestinal tract. Prognostic researches are carried out for choosing the optimum therapy, evaluating therapy results and comparing multicentre results for better qualification in the therapy of the disease.

PATIENTS AND METHODS

In this study, 448 patients, whose surgery and follow-up was performed by the same correspondent surgeon between the years 1995 and 2003, were retrospectively analyzed.

RESULTS

Age, presence of comorbidity, weight loss, emergency admission, high serum CEA and CA 19-9 levels, neighboring organ invasion, operation type, major morbidity, tumor size and type, lymph node metastases, venous and perineural invasion, Dukes' classification and local recurrence and distant metastasis during follow-up are found to be significant negative factors affecting prognosis of the CRC patient.

CONCLUSION

Therapy results of the CRC are evaluated by survival times regardless of the therapy method selected for each individual. In our study we tried to find out negative prognostic factors by researching possible factors affecting disease free survival time for CRC. Since our understanding of factors that have an impact on prognosis increases, we are hoping to improve survival.

Reoperation for recurrent colorectal cancer

Recurrence of colorectal carcinoma represents a significant challenge. As the majority of recurrences involve more than just the anastomosis, surgical resection is ordinarily a major undertaking. Curative resection may require resection of other organs and structures, resulting in complex reconstructive procedures and substantial morbidity. In addition, carefully selected patients with distant metastases to sites such as the liver and lungs may also undergo potentially curative resection. Long-term survival following curative surgery for recurrence, however, ranges from only 15 to 40%. In addition to resection for curative intent, some patients may benefit from palliative procedures designed to relieve symptoms. Surgery alone is not usually sufficient therapy in these patients. Chemotherapy and radiation therapy play a vital adjunctive role in the management of recurrent disease. This article strives to review the risk factors and patterns of recurrence, selection of individuals for resection of recurrent disease, and outcomes of surgical procedures.

Recidiva local en el cáncer de colon y recto

Data on the incidence of colorectal cancer are alarming and reveal that it is currently the second cause of death from cancer. Most of these deaths are due to recurrence after surgery with curative intent. The factors associated with locoregional recurrence are mainly related to the tumor's histopathological characteristics and grade of invasion. With adequate training the surgeon should not appear among these factors. In rectal cancer this training involves the technique of mesorectal excision, adequate circumferential margin and selective neoadjuvant chemoradiotherapy. After curative resection, patients should be followed-up to detect asymptomatic recurrence. Isolated local recurrence occurs in 20-30% of patients, but even with liver or lung metastases curative surgery can be attempted and success depends on correct multidisciplinary preoperative evaluation. If the diagnosis is made when the tumor is in an incurable phase, the aim is to improve the patient's quality of life.

Hydronephrosis Does Not Preclude Curative Resection of Pelvic Recurrences After Colorectal Surgery

BACKGROUND

In one third of patients who die of rectal cancer, a pelvic recurrence after resection represents isolated disease for which re-resection may provide cure. These extensive resections can carry high morbidity. Proper patient selection is desirable but difficult. Hydronephrosis has been documented previously to portend a poor prognosis, and some consider it a contraindication to attempted resection. It was our goal to review our experience and either confirm or refute these conclusions.

METHODS

We performed a retrospective analysis of 90 patients resected with curative intent for pelvic recurrence at our center from 1988 through 2003. Seventy-one records documented the preoperative presence or absence of hydronephrosis. Clinical and pathologic data were recorded. The groups with and without hydronephrosis were compared.

RESULTS

There were 15 patients with hydronephrosis in this study and 56 without. Although patients with hydronephrosis had shorter overall survival, disease-free survival, and rate of local control, none of these differences was statistically significant. Patients in the hydronephrosis group were younger and had higher-stage primary tumors and larger recurrent tumors. Subsequently, they underwent more extensive resections and were more likely to be treated with adjuvant therapies. There was no difference in the rate of margin-negative resections between the groups.

CONCLUSIONS

Hydronephrosis correlates with younger patients with larger recurrent tumors undergoing more extensive operations and multimodality therapy but does not preclude curative (R0) resection or independently affect overall survival, disease-free survival, or local control. We believe that it should not be considered a contraindication to attempting curative resection.

Recurrences after peritoneal carcinomatosis of colorectal origin treated by cytoreduction and hyperthermic intraperitoneal chemotherapy: location, treatment, and outcome

BACKGROUND

After treatment of peritoneal carcinomatosis of colorectal cancer origin by cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC), recurrences develop in approximately 80% of patients. This study evaluates the outcome of such recurrences after initial treatment by cytoreduction and HIPEC.

METHODS

Between November 1995 and May 2003, 106 patients underwent cytoreduction and HIPEC. The progression-free interval, the location of the recurrence, and its treatment were recorded. Factors potentially related to survival after recurrences were studied.

RESULTS

Sixty-nine patients had a recurrence within the study period. For patients who had undergone a gross incomplete initial cytoreduction, the median duration of survival after recurrence was 3.7 months (standard error of the mean [SE], .3). If a complete cytoreduction had been accomplished initially, the median duration of survival after the recurrence was 11.1 months (SE, .9). A shorter interval between HIPEC and recurrence was associated with shorter survival after treatment of recurrence (hazard ratio, .94; SE, .02). After effective initial treatment, a second surgical debulking for recurrent disease resulted in a median survival duration of 10.3 months (SE, 1.9), and after treatment with chemotherapy it was 8.5 months (SE, 1.6). The survival was 11.2 months (SE, .5) for patients who received radiotherapy for recurrent disease. Patients who did not receive further treatment survived 1.9 months (SE, .3).

CONCLUSIONS

Treatment of recurrence after cytoreduction and HIPEC is often feasible and seems worthwhile in selected patients. Selection should be based mainly on the completeness of initial cytoreduction and the interval between HIPEC and recurrence.