Lumboaortic and iliac lymphadenectomy: what is the role today?

PURPOSE

The aim of this study was to evaluate the roles of the lymphadenectomy in the surgical treatment of rectal cancer.

METHODS

On the basis of our experience of 252 curative operations for rectal cancer, we analyze survival and recurrence in relation to the lymph node involvement and to the level of the lymph nodes where the metastases are located. All patients underwent a lymphadenectomy with high ligation of the inferior mesenteric artery and removal of the lumboaortic lymph nodes from the left renal vein to the aortic bifurcation. Pelvic lymphadenectomy was performed in 16 cases.

RESULTS

Five-year survival was 70.6 percent in patients with no lymph node involvement, 68.2 percent in patients with pararectal lymph nodes N+, 25 percent in patients with involvement of intermediate lymph nodes, and 30 percent in patients with involvement of lumboaortic lymph nodes. In no case was there involvement of the hypogastric lymph nodes. On the basis of our experience and from results in the literature, we consider an upward extended lymphadenectomy with high ligation of the inferior mesenteric artery is warranted since it enables the tumor to be staged accurately and may lead to survival even in cases of advanced lymph node involvement.

Ultrasound and Doppler features of accessory spleens and splenic grafts

16 splenic grafts and 24 accessory spleens were evaluated with ultrasound, colour Doppler and power Doppler imaging, in order to compare the features of splenic grafts and accessory spleens. 12 splenic grafts (11 surgically implanted, 1 islet of splenosis) were detected in eight patients following splenectomy 6-12 months previously. Four of the surgically implanted splenic grafts were found in three patients following splenectomy 16-18 days previously. 21 accessory spleens were incidentally detected in 20 subjects who had not been operated upon, whereas three enlarged accessory spleens were found in 10 patients who underwent splenectomy 6-12 months previously. The size, shape, rim features, echogenicity, acoustic enhancement and vascularization of the splenic grafts and accessory spleens were evaluated. The splenic grafts were oval with lobulated margins, an inhomogeneous pattern in 36% and acoustic enhancement in 64%. Multiple feeding vessels arising from the surrounding tissue entered the periphery of 10 splenic grafts in the eight patients operated on 6-12 months previously, whereas no vascular signals were detected in the four splenic grafts of the three patients operated on 16-18 days ago. Accessory spleens were round with smooth echogenic margins and a vascular hilum arising from the splenic vessels. In conclusion colour Doppler and power Doppler allow differentiation between accessory spleens and splenic grafts basing on their shape and vascular supply.

Local excision for rectal cancer

BACKGROUND AND OBJECTIVES

The aim of this retrospective study is to evaluate the results of local excision (LE) for rectal cancer for curative purposes.

METHODS

From 1969 to December 1997, a total of 456 operations were performed for surgical treatment of rectal carcinoma (262 males and 194 females, mean age 66 years). Twenty patients (4.1%) underwent LE (7 males and 13 females, median age 65 years). Patients were selected for LE if they met the following criteria during preoperative staging: tumors staged as T1-T2,N0,M0, grading G1 or G2, and accessible location. Types of LE performed were: 13 transanal excisions (Francillon's technique), 2 Mason surgeries, 2 endoscopic excisions, and 3 transanal endoscopic microsurgeries.

RESULTS

There was no in-hospital mortality among LE patients. Thirteen tumors were T1 and 7 were T2; all 20 were adenocarcinoma, 14 G1 and 6 G2. There was no specific morbidity, and aspecific morbidity was minimal (5%). There were no local recurrences, but 2 patients (10%) had secondary lesions. Five-year overall survival following LE was 87.4%. Comparing T1 and T2 tumors treated with abdominoperineal resection (APR) and SSR (17 T1 and 42 T2, all adenocarcinoma), in-hospital mortality and specific morbidity were respectively 1.7% (P = 0.55) and 28% (P = 0.007). There were 5 (8.5%) local recurrences (P = 0.17) and 6 (10.2%) metastatic lesions. Five-year overall survival was similar to LE (88.3%; P = 0.76).

CONCLUSIONS

LE for rectal carcinoma might only be successfully performed in selected patients with correct preoperative staging. In the LE cases reported five-year overall survival, local recurrence, and in-hospital mortality were similar to APR and SSR, while there was a statistically significant difference following LE in terms of specific morbidity.

[DNA ploidy and cell kinetics in cancer of the rectum]

The pathological assessment of rectal cancer remained essentially unchanged for 50 years and it is based mainly on Dukes' classification and histological granding. Alternative methods of classifications have also been developed but, actually, Dukes'taging is the most important prognostic factor. The limit of Dukes' classification is the incomplete discrimination between high risk and low risk patients into the same stages. The measurements of cellular DNA content by flow cytometry is emerging as a prognostic aid in many human tumours. Authors analyze on the basis of their experience on 116 curative operations for the cancer of the rectum, the relationship between tumour's features, CEA, symptoms, recurrences, survival, type of operation and DNA flow cytometry. In 100 cases they studied the percentage of cells in "s" phase. (SPF). Samples of flow-cytometry were prepared using paraffin-embedded tumour blocks. The authors didn't find any statistically significant relation among pathological features, staging, ploidy and SPF. Recurrences rate was 16.6% in diploid tumours and 23% in no diploid (p = 0.3). In SPF < 25% it was 18.2% (p = 0.5). 5-year survival was worse in aneuploid patients (p = 0.06). Using Cox' multivariate regression analysis, ploidy has not independent prognostic significance. In conclusion authors consider ploidy a prognostic factor in rectal cancer, but not independent. However, authors conclude that flow cytometry could help in early staging of the disease, especially in preoperative diagnosis. Flow cytometry has a prognostic significance with informations on tumoral biology and could contribute to select patients for adjuvant therapy or different surgical techniques.

[Conservative surgery in rectal cancer]

The Authors analyse their experience about 387 cases operated for rectal cancer. The choice of the operation was not related to tumour's features, but was related to the location of the neoplasia. The safety margin of rectal resection was reduced up to a minimum of 2 cm. in lower tumours, where it was not possible to meet this condition an abdomino-perineal resection was performed. A lumbo-aortic lymphadenectomy with high ligature of inferior mesenteric artery was always performed; in 17 cases it was extended to the pelvic nodes. In all the patients the whole mesorectum was removed and a wide pelvic dissection was performed to avoid the so called cone effect. Since 1991 all the B2-C patients undergo preoperative radiotherapy. Recurrence rate and survival are similar both after abdomino-perineal and sphincter-saving resections. Among the different risk factors, the Authors have found a statistically significant relation only with the stage. The Authors, therefore, conclude that sphincter-saving resection is the best surgical procedure because of the god quality of life. They stress the importance of a lumboarotic lymphadenectomy with high ligature of inferior mesenteric artery. As far as the complementary therapy is concerned, the discussion is still open, especially about the timing and the choice of the adjuvant treatment.

[Preoperative CEA: prognostic significance in colorectal carcinoma]

The prognostic meaning of preoperative CEA level and its relation to the other risk factors are still under debate. In 512 patients who underwent surgical treatment for colorectal cancer, CEA preoperative plasma level had been evaluated. The prognostic value of CEA was compared with other prognostic factors and the characteristics of the tumor. There was no significant ratio between CEA overexpression and stage, diameter, grading, ploidy, site and shape of the cancers. As regard as the long-term results are concerned, the patients with normal preoperative CEA levels had a better prognosis. In the Dukes B and C tumors, the level of CEA over the cut off point lets identify a group of patients with high risk whom more aggressive adjuvant therapies and follow up could be addressed to. This study suggests that CEA preoperative is an independent prognostic factor and may be useful in the therapeutic planning.

[Extended resection in locally advanced colon cancer]

Colorectal malignant tumors with a mono o multivisceral involvement have a poor prognosis and surgery is the only treatment with a hope to be curative. Aggressive surgical management of locally advanced colo-rectal cancer seems to be justified by good oncological results. At the Institute of Clinica Chirurgica of the University of Trieste 58 extended resections were performed for advanced tumors of colon and rectum. The specific morbidity rate was 24% for standard and 24.1% for extended resections. Operative morality was 15.2%; hystological specimen confirmed in 31 cases neoplastic infiltration of contigous structures. The 5 year survival rate was 38.5% in right colonic tumors and 53.3% in left colonic tumors. The literature favors an aggressive approach when the tumor adhesions are suspected. The excision of adjacent organs, whether or not they are microscopically involved by the tumor, is necessary to avoid leaving potentially curable disease The authors, analyzing their results, have also reported good results by management including resection of the colon and contigous organs if involved. Palliative therapy must be performed only if liver metastases are detected or in those cases when primary resection is not thecnically feable or in patients not able to tolerate the procedure.

[Low anterior resection in the curative surgical treatment of rectal cancer]

Abdominoperineal resection for rectal cancer are being performed with decreasing frequency in favour of sphincter-saving resections. It remains to be demonstrated that sphincter preservation has not resulted in compromised local disease control and survival. For this purpose 342 patients with rectal carcinoma have been studied. A curative resection has been carried out in 232. Sphincter-saving procedure was performed whenever possible: the length of margin of resection was at least 2 cm. The operation were: 71 abdominoperineal excisions (AP), 147 anterior resections (AR), 14 transanal excisions. The thirty-days mortality was 7 patients (9.9%) for AP and 5 (3.4%) for AR. Local recurrence was: AP 10 cases (15.6%), AR 16 cases (11.3%); for tumors 4-8 cm from anal verge recurrence was 17.1% for AP, 16.2% for AR. Concerning staging, local recurrence was more common in the Dukes C stage (24.3%) than in the Dukes B (10.2%) or in the Dukes A (3.8%). 5 years survival after AP was 62.2 percent and after AR 67.9 percent. Concluding, in our experience, there was no relationship between local recurrence or survival and type of curative surgery (AP or AR). Local recurrence and survival were only related to tumor stage: lateral tumor extension in these advanced and aggressive lesions appears to be the major determinant of local recurrence. Further investigations are necessary to determine whether the addition of adjuvant radiotherapy or of extended abdomino-iliac lymphadenectomy should be able to improve the results.

[Current trends in the treatment of rectal carcinoma]

Authors report their personal experience about 336 cases of curative surgery for rectal cancer. They describe technical surgical details universally accepted in Literature such as sharp total mesorectal excision, the extension of lymphadenectomy with high ligature of inferior mesenteritis artery while pelvic lymphadenectomy seems to be unuseful and burdened by high morbidity; finally they underline advantages offered by a colic pouch above all for lower incidence of anastomotic leakages. As adjuvant therapy is concerned, our actual tendency is a preoperative radiochemiotherapy of which we are still evaluating long-term results. Finally we analyzed correlations between cellular genetics and colo-rectal cancer.

[Surgical therapy of right colon cancer]

The debate about the management of frequent advanced right colon cancer is still opened: the opportunity of extended resections when the surrounding organs or tissues are infiltrated, the lymphadenectomy extension and its role, the possibility of identifying prognostic factors that could be useful to decide adjuvant therapy, the definition of the role of laparoscopy. Considering these problems, we have reviewed a series of 159 operations performed by the Institute of Clinical Surgery of the University of Trieste from 1980. 112 of these operations had a curative goal. The reconstruction of intestinal continuity was carried out manually in 28 cases and with mechanical stapler in 78. As far as the curative resection are concerned, in 89 of them an extended lymphadenectomy was performed (D3), while in 18 cases the lymphadenectomy was limited to the lymph nodes of first and second level due to the general bed conditions of the patient. 27 of the curative exeresis were performed in patients with T4 tumor infiltrating the nearby tissues. Referring to Dukes' classification, 8 were included in stage A, 59 in stage B and 40 in stage C, while as far as the depth of wall infiltration is concerned 2 were categorized as T1, 9 as T2, 69 as T3 and 27 as T4. The overall operative mortality was of 5 patients, the overall morbidity of 14%, that specific of 4.6%. The final incidence of local recurrences was 13.8% for Dukes A cancers, 10.9% for Dukes B and 120.5% for Dukes C (p = 0.0614). Half of the recurrences (50%) occurred in patients with a cancer infiltrating the nearby tissues. The 5 year survival rate for patients with Dukes A lesions was 100%, for patients with Dukes B lesions 73.4% and for Dukes C 52.3% (p = 0.00510). With Cox' multivariate analysis only the stage disease, T and grading showed a significative correlation with the survival rate. Our experience, therefore, suggests the execution of an exeresis with lymphadenectomy D3 in each cases where the local site of the lesion and the general conditions of the patients allow it and an extended exeresis where possible from a technical point of view and when the lymph nodes are involved.

[Role of curative local excision in rectal cancer]

The aim of this retrospective study is to evaluate the results of local excision (LE) for rectal cancer for curative purposes. From 1969 to December 1997, a total of 456 operations were performed for surgical treatment of rectal carcinoma (262 males and 194 females, mean age 66 years). 20 patients (4.1%) underwent LE, 7 males and 13 females, median age 65 years. Patients were selected for LE if they met the following criteria during preoperative staging: tumors staged as T1-T2, N0, M0, grading G1 or G2, achievable location. As far as the type of LE is concerned, 13 transanal excisions (Francillon technique), 2 Mason, 2 endoscopic excisions and 3 TEM were performed. Among patients who underwent LE there was no operative mortality. 13 tumors were T1 and 7 were T2; pathologic findings included 20 adenocarcinoma, 14 G1 and 6 G2. There was no postoperative specific morbidity, while aspecific morbidity was minimal (5%). There were no local recurrences but 2 patients (10%) had secondary lesions. Five year overall survival following LE was 87.4%. Comparing T1 and T2 tumors after APR and SSR (17 T1 and 42 T2, all adenocarcinoma), operative mortality and specific morbidity were respectively 1.7% (p = 0.55) and 28% (p = 0.007). There were 5 (8.5%) local recurrences (p = 0.17) and 6 (10.2%) metastatic lesions. Five year overall survival was similar to LE (88.3%; p = 0.76). In conclusion the authors stress the importance that IE for rectal carcinoma must be performed only in selected patients provided there is correct preoperative staging. In these cases five year overall survival, local recurrence and operative mortality were similar to APR and SSR, while there was a statistically significative difference following LE in terms of specific morbidity.

[Functional complications of the lower urinary tract after curative exeresis for cancer of the rectum]

The aim of the study is to assess the incidence and the pathogenesis of urinary dysfunction in the surgical treatment of rectal cancer. A series of 219 patients, who underwent surgery for rectal cancer with normal urinary preoperative function, was submitted to a prospective follow-up for the urinary function. Symptomatic patients in the follow-up were studied by ultrasonography, cystomanometry and pressure-flow electromyography. In the immediate follow-up only 17 patients with urinary dysfunction were observed (14 at stage 2, 2 at stage 3 an1 at stage 4 according Saito classification). Six months later only 8 patients had urinary dysfunction. In 1 of these cases neurogenic bladder requiring catheterization was observed no significative correlation with staging, radiotherapy, size of tumor, surgical technique was observed. Worst functional results were observed in patients who underwent abdomino-perineal resections.

[Emergencies in colorectal carcinoma: negative prognostic factor?]

The authors analyze a consecutive series of 219 patients affected by complicated colorectal cancer who underwent surgery in emergency. In hospital mortality, 5-year survival and recurrence's incidence in 104 of these patients who underwent curative treatment are calculated and compared with a series of 701 patients who underwent elective surgical treatment. There was no significative statistical difference between emergency and elective group. At the multivariate analysis only the stage of the tumor was an independent prognostic factor.

[Low anterior resection in the curative surgical treatment of rectal cancer]

Abdominoperineal resections for rectal cancer are being performed with decreasing frequency in favour of sphincter-saving resections. It remains to be demonstrated that sphincter preservation has not resulted in compromised local disease control, disease-free survival and survival. For this purpose 315 patients with rectal carcinoma have been studied. In 44 cases (13.9%) it was only possible to perform a colostomy; a curative resection has been carried out in 206 (65.3%). Sphincter-saving procedure was performed whenever possible: the length of margin of resection was at least 2 cm. The operation were: 61 abdominoperineal excisions (AP), 135 anterior resections (AR), 10 transanal excisions (excluded from this analysis). The distribution of tumors in the various Duke's stages was: Dukes A--28 patients, Dukes B--143, Dukes C--35. The thirty-days mortality was 6 patients (9.8%) for AP and 6 (4.4%) for AR. Local recurrence was: AP 9 cases (16.1%), AR 16 cases (12.4%); for tumors 4-8 cm from anal verge recurrence was 18.7% for AP, 17.1% for AR. Concerning staging, local recurrence was more common in the Dukes C stage (36%) than in the Dukes B (11.2%) or in the Dukes A (3.7%). 5 years survival after AP was 54.6 percent and after AR 57.9 percent. Concluding, in our experience, there was no significant relationship between local recurrence or survival and type of curative surgery (AP or AR). Local recurrence and survival were only related to tumor stage (p less than 0.01): lateral tumor extension in these advanced and aggressive lesions appears to be the major determinant of local recurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

[Serous cysts of the transverse mesocolon: a review of the literature in the light of 2 cases brought to our notice]

Mesenteric cyst is one of the rarest tumours, with about 820 cases reported since 1507. Ultrasound and TC are the most valuable modalities for diagnosis of mesenteric cyst. Surgical resection is the treatment of choice. The authors report two cases of mesenteric cyst of the transverse mesocolon preoperatively diagnosed by ultrasonography and computed tomography (CT). A surgical enucleation was performed.

[Role of intensive follow-up in colorectal cancer surgery patients]

Authors analyze the role of follow-up after curative resection for colo-rectal cancer. In 129 patients (29.6%) a recurrence was observed, whilst in 6 (1.4%) a metachronous carcinoma was detected by endoscopy. Liver involvement was observed in 59 patients, lung metastasis in 18 and both liver and lung metastasis in 4. In 23 patients local recurrence (LR) was observed and in 25 both LR and liver metastasis were detected. 31 patients (24%) were submitted to surgery and 21 (16.2%) with curative purpose. As far as LR is concerned, 5 patients were operated (10%) with curative purpose and a 5 years survival of 40% was observed. Five years survival in 9 patients submitted to surgery with curative purpose (8.4%) for liver metastasis was 57.1%, whilst in 7 patients operated for lung metastasis (31.8%) it was 76%. All the 6 patients operated for metachronous carcinoma are still alive with a 2-5 years follow-up.