Early rectal cancer: The diagnostic performance of MRI supplemented with a rectal micro-enema and a modified staging system to identify tumors eligible for local excision

Background

In staging early rectal cancers (ERC), submucosal tumor depth is one of the most important features determining the possibility of local excision (LE). The micro-enema (Bisacodyl) induces submucosal edema and may hypothetically improve the visualization of tumor depth.

Purpose

To test the diagnostic performance of MRI to identify ERC suitable for LE when adding a pre-procedural micro-enema and concurrent use of a modified classification system.

Material and Methods

In this prospective study, we consecutively included 73 patients with newly diagnosed rectal tumors. Two experienced radiologists independently interpreted the MRI examinations, and diagnostic performance was calculated for local tumors eligible for LE (Tis-T1sm2, n = 43) and non-local tumors too advanced for LE (T1sm3-T3b, n = 30). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were registered for each reader. Inter- and intra-reader agreements were assessed by kappa statistics. Lymph node status was derived from the clinical MRI reports.

Results

Reader1/reader2 achieved sensitivities of 93%/86%, specificities of 90%/83%, PPV of 93%/88%, and NPV of 90%/81%, respectively, for identifying tumors eligible for LE. Rates of overstaging of local tumors were 7% and 14% for the two readers, and kappa values for the inter- and intra-reader agreement were 0.69 and 0.80, respectively. For tumors ≤T2, all metastatic lymph nodes were smaller than 3 mm on histopathology.

Conclusion

MRI after a rectal micro-enema and concurrent use of a modified staging system achieved good diagnostic performance to identify tumors suitable for LE. The rate of overstaging of local tumors was comparable to results reported in previous endorectal ultrasound (ERUS) studies.

One-year results of the SCANDIV randomized clinical trial of laparoscopic lavage versus primary resection for acute perforated diverticulitis

Background

Recent randomized trials demonstrated that laparoscopic lavage compared with resection for Hinchey III perforated diverticulitis was associated with similar mortality, less stoma formation but a higher rate of early reintervention. The aim of this study was to compare 1-year outcomes in patients who participated in the randomized Scandinavian Diverticulitis (SCANDIV) trial.

Methods

Between February 2010 and June 2014, patients from 21 hospitals in Norway and Sweden presenting with suspected perforated diverticulitis were enrolled in a multicentre RCT comparing laparoscopic lavage and sigmoid resection. All patients with perforated diverticulitis confirmed during surgery were included in a modified intention-to-treat analysis of 1-year results.

Results

Of 199 enrolled patients, 101 were assigned randomly to laparoscopic lavage and 98 to colonic resection. Perforated diverticulitis was confirmed at the time of surgery in 89 and 83 patients respectively. Within 1 year after surgery, neither severe complications (34 versus 27 per cent; P = 0·323) nor disease-related mortality (12 versus 11 per cent) differed significantly between the lavage and surgery groups. Among the 144 patients with purulent peritonitis, the rate of severe complications (27 per cent (20 of 74) versus 21 per cent (15 of 70) respectively; P = 0·445) and disease-related mortality (8 versus 9 per cent) were similar. Laparoscopic lavage was associated with more deep surgical-site infections (32 versus 13 per cent; P = 0·006) but fewer superficial surgical-site infections (1 versus 17 per cent; P = 0·001). More patients in the lavage group underwent unplanned reoperations (27 versus 10 per cent; P = 0·010). Including stoma reversals, a similar proportion of patients required a secondary operation (28 versus 29 per cent). The stoma rate at 1 year was lower in the lavage group (14 versus 42 per cent in the resection group; P < 0·001); however, the Cleveland Global Quality of Life score did not differ between groups.

Conclusion

The advantages of laparoscopic lavage should be weighed against the risk of secondary intervention (if sepsis is unresolved). Assessment to exclude malignancy (although uncommon) is advised. Registration number: NCT01047462 (http://www.clinicaltrials.gov).

Microsatellite instability has a positive prognostic impact on stage II colorectal cancer after complete resection: results from a large, consecutive Norwegian series

Background

Microsatellite instability (MSI) was suggested as a marker for good prognosis in colorectal cancer in 1993 and a systematic review from 2005 and a meta-analysis from 2010 support the initial observation. We here assess the prognostic impact and prevalence of MSI in different stages in a consecutive, population-based series from a single hospital in Oslo, Norway.

Patients and methods

Of 1274 patients, 952 underwent major resection of which 805 were included in analyses of MSI prevalence and 613 with complete resection in analyses of outcome. Formalin-fixed tumor tissue was used for PCR-based MSI analyses.

Results

The overall prevalence of MSI was 14%, highest in females (19%) and in proximal colon cancer (29%). Five-year relapse-free survival (5-year RFS) was 67% and 55% (P = 0.030) in patients with MSI and MSS tumors, respectively, with the hazard ratio (HR) equal to 1.60 (P = 0.045) in multivariate analysis. The improved outcome was confined to stage II patients who had 5-year RFS of 74% and 56% respectively (P = 0.010), HR = 2.02 (P = 0.040).

Examination of 12 or more lymph nodes was significantly associated with proximal tumor location (P < 0.001).

Conclusions

MSI has an independent positive prognostic impact on stage II colorectal cancer patients after complete resection.

Peritoneal carcinomatosis of colon cancer origin: highest incidence in women and in patients with right-sided tumors

BACKGROUND AND OBJECTIVES

The aim of the study was to evaluate the incidence of peritoneal carcinomatosis (PC) in a prospectively recorded series of colon cancer patients from a defined cohort and to compare clinicopathological characteristics, survival, and TP53 mutation status in primary tumors from patients with and without PC.

METHODS

Clinical data from all colon cancer patients admitted in 1993-2006 were registered prospectively (n = 1,124). In a subset of PC patients, DNA was retrieved from tumor tissue and TP53 mutations analyzed and compared to the mutation status in a historical series.

RESULTS

In the prospective series 10% of female and 7% of male patients had PC (P = 0.05). The PC patients were younger than those without PC (median 4 years, P = 0.002). The incidence of PC was 10.3% and 6.2% (P = 0.03) in patients with primary tumors in the right and left colon, respectively. TP53 was mutated in 57% of the PC patients as compared to 41% in the series of patients without PC (P = 0.05).

CONCLUSIONS

The incidence of PC was higher in right-sided colon cancer and among women. PC patients were younger than non-PC patients, and PC was independently associated with TP53 mutation in the primary tumor.

Short term outcome after emergency and elective surgery for colon cancer

OBJECTIVE

Emergency presentation of colon cancer is common and associated with high mortality and morbidity following surgical treatment. The purpose of this study was to evaluate postoperative mortality and complications in a consecutive and population based series.

METHOD

All patients with adenocarcinoma of the colon diagnosed between 1993 and 2007 were registered prospectively. Postoperative mortality and complication rates in elective and emergency patients were compared. Logistic regression analysis was used to identify independent risk factors for postoperative complications.

RESULTS

In the study period 1129 patients were admitted, of whom 279 (25%) presented as an emergency. A total of 999 (89%) patients underwent surgical treatment; 924 patients (82%) had a major resection. The mortality rate was 3.5% after elective and 10% after emergency operation with resection (P < 0.01), and the complication rate was 24% and 38% (P < 0.01), respectively. In patients with left-sided obstruction, the mortality rate after Hartmann's procedure was 19% compared to 3% after resection with primary anastomosis (P < 0.01). Multivariate analyses demonstrated that emergency operation, increasing age, advanced tumour stage and ASA class IV were independent risk factors for postoperative mortality.

CONCLUSION

Emergency operation for colon cancer was associated with high rates of complications and mortality, indicating that immediate surgery should be avoided if possible. Decompression of left sided obstruction with a stent seems promising, whereas no conclusion can be made with regard to optimal procedure if stent placement fails; in this study Hartmann's procedure was associated with high mortality and morbidity.

Tumour location is a prognostic factor for survival in colonic cancer patients

OBJECTIVE

To evaluate survival and prognostic factors in a consecutive series of colon cancer patients from a defined city population in Norway.

METHOD

All patients with adenocarcinoma of the colon diagnosed between 1993 and 2000 were registered prospectively. Five-year actuarial survival and 5-year relative survival rates were calculated. Cox regression analyses were used to study the effect of prognostic factors on survival.

RESULTS

In the study period 627 patients were admitted. Overall 5-year relative survival was 50% in females and 52% in males. Five-year relative survival in 410 (65%) patients operated with curative intent, was 74% for females and 79% for males. Tumour location in the transverse colon, splenic flexure and descending colon (OR = 1.8), emergency operation (OR = 1.7), TNM stage (OR = 1.8-2.9), blood transfusion of more than two units (OR = 1.8) and age (OR = 4.0-7.1) were independent negative prognostic factors.

CONCLUSION

Colon cancer located in the transverse and descending colon is associated with poor prognosis. Comparison of results from different centres is difficult due to selection and classification differences, and different methods used for calculation of survival.

[Necrotising fasciitis--a surgical challenge]

Necrotizing fasciitis is a severe, potentially fatal, soft tissue infection. Group A streptococci are the main infectious agents. Early surgical treatment is decisive for the outcome. This report includes 20 patients treated consecutively during a four and a half year period, ten women and ten men, 28 to 78 years of age. Condition at admission to hospital, time from symptom appearance to operation, treatment and results are described. All patients had signs of local infection with rubor and swellings. Severe localized pain was typical. Surgical diagnostic exploration confirmed the diagnosis and led to prompt surgical debridement of all affected tissues. Three patients died, 12 survived without severe sequela and five survived with amputated leg or arm. Necrotizing fasciitis has changed from being a rare disease primarily affecting immunocompromised patients to occurring more frequently also among otherwise healthy individuals. By diseases with local soft tissue infection a liberal use of surgical exploration leads to diagnosis. Increased knowledge of the disease and adherence to a treatment protocol based on antibiotic therapy and mandatory aggressive surgery has probably improved the results with no case fatality in the latter half of the study period.