Irrigation does not dislodge or destroy tumor cells adherent to the tumor bed

Continuous saline bladder irrigation for two hours following transurethral resection of bladder tumors in patients with non-muscle invasive bladder cancer does not prevent recurrence or progression compared with intravesical Mitomycin-C

BACKGROUND

Intravesical Mitomycin-C (MMC) following transurethral resection of bladder tumor (TURBT), while efficacious, is associated with side effects and poor utilization. Continuous saline bladder irrigation (CSBI) has been examined as an alternative. In this study we sought to compare the rates of recurrence and/or progression in patients with NMIBC who were treated with either MMC or CSBI after TURBT.

METHODS

We retrospectively reviewed records of patients with NMIBC at our institution in 2012-2015. Perioperative use of MMC (40 mg in 20 mL), CSBI (two hours), or neither were recorded. Primary outcome was time to recurrence or progression. Descriptive statistics, chi-squared analysis, Kaplan-Meier survival analysis, and Cox multivariable regression analyses were performed.

RESULTS

205 patients met inclusion criteria. Forty-five (22.0%) patients received CSBI, 71 (34.6%) received MMC, and 89 (43.4%) received no perioperative therapy. On survival analysis, MMC was associated with improved DFS compared with CSBI (p = 0.001) and no treatment (p = 0.0009). On multivariable analysis, high risk disease was associated with increased risk of recurrence or progression (HR 2.77, 95% CI: 1.28-6.01), whereas adjuvant therapy (HR 0.35, 95% CI: 0.20-0.59) and MMC (HR 0.43, 95% CI: 0.25-0.75) were associated with decreased risk.

CONCLUSIONS

Postoperative MMC was associated with improved DFS compared with CSBI and no treatment. The DFS benefit seen with CSBI in other studies may be limited to patients receiving prolonged irrigation. New intravesical agents being evaluated may consider saline as a control given our data demonstrating that short-term CSBI is not superior to TURBT alone.

Safety and efficacy of dehydrated ethanol soaking of the operative field in the treatment of spontaneous hepatocellular carcinoma rupture

Background

The aim of our study was to evaluate the clinical safety and value of ethanol surgical field infiltration (ESFI), combined with distilled water peritoneal lavage (DWPL), after hepatectomy in patients with hepatocellular carcinoma (HCC) rupture.

Methods

Rat liver tissue samples were soaked in dehydrated ethanol for different soaking times, and 18 rats were assigned to three groups that underwent different soaking methods of the hepatectomy cut surface. We retrospectively reviewed 45 patients who underwent hepatectomy for treatment of ruptured HCC. Among these, EFSI combined with DWPL was used in 21 patients (DAW group), with only DWPL used in the other 24 patients (DW group). Clinical outcomes were compared between the two groups.

Results

For in vitro experiments, the depth of coagulation degeneration and necrosis increased with the duration of soaking. For in vivo experiments, rats in all three groups survived until postoperative day 7 without significant postoperative complication. In patients, the rate of post-operation complication was comparable between the two groups (P = 0.398), with no between-group differences in liver function levels. The incidence of peritoneal dissemination was significantly higher for DW than DAW group (P = 0.037). Kaplan–Meier test identified dehydrated ethanol treatment as a significant factor of disease-free survival (DFS) (P = 0.036). On univariate analysis, dehydrated ethanol treatment was associated with better prognostic outcomes, although it was not retained as an independent factor of patient outcome.

Conclusions

Dehydrated ethanol soaking of the cut surface of the hepatectomy could potentially lower the risk of metastasis and improve the effect of hepatectomy for ruptured HCC as well as showed potential therapeutic value for intraoperative iatrogenic rupture of HCC.

Electronic supplementary material

The online version of this article (10.1186/s12957-018-1390-x) contains supplementary material, which is available to authorized users.

Intraperitoneal Hyperthermic Chemotherapy in Gastric Cancer: Rationale for a new Approach

There is preliminary evidence from experience in the treatment of various abdominal malignancies that intraperitoneal chemotherapy alone or combined with hyperthermia may attain a role in the therapeutic strategy. This paper considers the rationale for such an approach, as well as its current results and potential indications in patients with gastric cancer. The literature is critically reviewed, with special emphasis on specific topics such as patterns of tumor spread, mechanisms of local recurrence, the rationale for intraperitoneal chemotherapy and intraperitoneal hyperthermic chemotherapy, toxicity, and results from non-controlled as well as randomized clinical trials in patients with gastric cancer. There is some evidence that intraperitoneal hyperthermic chemotherapy has a favorable effect on clinical outcome in patients with limited peritoneal carcinomatosis or malignant ascitis and in those at risk of future peritoneal spread, such as patients with pT3-pT4 cancers or with positive cytology of the peritoneal fluid. Hyperthermic chemotherapy should be considered a promising approach in limited or impending peritoneal carcinomatosis, and should be included in the multidisciplinary approach to the treatment of locally advanced gastric cancer.

Treatment and prevention of peritoneal carcinomatosis from gastric cancer by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: overview and rationale

Peritoneal carcinomatosis (PC) from gastric cancer is a condition with a very bleak prognosis. Most authors consider it to be a terminal disease and recommend palliative therapy only. Multimodal therapeutic approaches to PC have emerged in the last decades, combining cytoreductive surgery (CRS) and peritonectomy procedures with perioperative intraperitoneal chemotherapy (IPEC), including hyperthermic intraperitoneal chemotherapy (HIPEC) and/or early postoperative intraperitoneal chemotherapy (EPIC). We reviewed the pertinent literature concerning the HIPEC modality both for the treatment of established PC and the prevention of peritoneal recurrence after potentially curative gastric cancer (GC) surgery. Basically, the two procedures relate to different aspects of GC and they are not comparable, since the latter has been used as an adjuvant when PC is still not macroscopically evident and the former has been exclusively used in advanced gastric cancer stages with peritoneal dissemination. Data supporting beneficial effects once gastric PC is already manifest is scarce and limited to few centres with specific experience in this field. Conversely, with regards to the peritoneal perfusion for preventing PC in high risk gastric cancer patients, there are phase III trials and meta-analysis which support beneficial effects resulting from the HIPEC procedure. To offer a baseline guide, we summarized the actual status and general outcome obtained by this multimodal technique, in association or not with CRS as treatment of advanced GC.

Splenectomy ameliorates hematologic toxicity of hyperthermic intraperitoneal chemotherapy

BACKGROUND

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy is a promising modality for peritoneal carcinomatosis. Splenectomy is frequently required, however effect upon hematotoxicity is unknown.

METHODS

195 patients undergoing the procedure were evaluated and granulocyte colony stimulating factor administered for white blood cell counts <4.0.

RESULTS

52% of 195 underwent splenectomy; average white blood cell and platelet nadirs were 6.1,172. Non-splenectomy patients averaged white blood cell nadir 4.6, platelet nadir 164.1. Granulocyte colony stimulating factor administered in 29% of splenectomy, 43% of non-splenectomy (P=0.043).

CONCLUSION

Splenectomy ameliorates hematotoxicity of hyperthermic intraperitoneal chemotherapy and significantly reduces post-operative granulocyte colony stimulating factor requirements.

Proactive management of peritoneal metastases from colorectal cancer: the next logical step toward optimal locoregional control

SUMMARY Although surgery for colorectal cancer has improved over the last decade, locoregional recurrence and peritoneal metastases continue as a mechanism of surgical treatment failure in 10–20% of patients. These patients have a dismal prognosis. Clinical information is available in order to identify patients who are at high risk for locoregional recurrence and peritoneal metastases. These patients, once identified, should be offered new treatment options shown to be of benefit in selected patients. Using perioperative chemotherapy at the time of colorectal cancer resection improves locoregional control and diminishes peritoneal metastases. Also, in patients at high risk, a proactive second-look surgery utilizing peritonectomy and hyperthermic intraperitoneal chemotherapy is of benefit, with reasonable morbidity and mortality.

Washout after lobectomy: is water more effective than normal saline in preventing local recurrence?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: 'is water washout more effective than normal saline washout after lobectomy in preventing local recurrence?' Altogether more than 48 papers were found using the reported search, of which nine represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Tumour cell 'spillage' after cancer resection is linked to a worse prognosis, so washout to minimize contamination is an established surgical technique. While the mechanical effects of lavage are well validated, the differential cytocidal effects of water versus saline as irrigation fluids are not. There are currently no studies addressing this issue in the thoracic surgery setting, after lung cancer lobectomy. However, the majority of relevant papers describe the use of basic in vitro methods and animal models to produce data that can conceivably be extrapolated to the clinical question in hand. The number of studies is small, and some have technical limitations. While two of the better-designed experiments suggest that water exerts a superior cytocidal effect on tumour cells, data from other studies are somewhat unimpressive, with two studies reporting that water washout controls tumour growth to a lesser extent than saline. This, together with the complete paucity of clinical trials on the subject, leads us to conclude that water is unlikely to represent a superior irrigation fluid in lung cancer patients after lobectomy.

Intraperitoneal hyperthermic chemotherapy: an evolving paradigm for the treatment of peritoneal surface malignancies

Unfortunately, advanced colorectal cancer is often present at the time the disease is diagnosed. Many intra-abdominal malignancies spread throughout the peritoneal cavity, which is known as carcinomatosis. Peritoneal carcinomatosis is uniformly a terminal disease with a median survival of 6 months. Systemic chemotherapy is palliative and generally provides limited improvement in survival. Conventional surgery has typically been limited to ileostomy, colostomy or intestinal bypass procedures. Cytoreductive surgery alone has long been used to treat macroscopic disease, with limited success. However, cytoreductive surgery combined with intraperitoneal hyperthermic chemotherapy (IPHC) has evolved into a novel approach for peritoneal surface malignancy. IPHC was initially described in a canine model by Spratt. Although the first clinical series of peritoneal perfusion were small, Japanese trials, which utilized IPHC for prophylaxis in patients with gastric adenocarcinoma, Fujimoto was the first to report an improvement in survival for established gastric cracinomatosis. This early work provided the proof-of-principle for what has evolved into current management with aggressive cytoreduction and IPHC. The present review will outline the rationale, current practice and future directions of IPHC in the management of peritoneal surface malignancies.

Cytoreductive surgery plus intraperitoneal chemohyperthermia in patients with colorectal cancer at high risk for local-regional recurrence

This article was written to define the situations in which early second-look surgery with a combined treatment should be indicated in patients at high risk of developing peritoneal carcinomatosis (PC). Through a review of the literature, this is a definition of the second-look concept and of the different groups of patients at risk, in different situations (after resection of the primary, after initial cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy, and after the discovery of isolated carcinoembryonic antigen elevation or isolated peritoneal uptake on positron emission tomography scan). Systematic second-look surgery for early treatment of asymptomatic PC is probably beneficial in patients presenting a high risk of developing PC after resection of their primary. The benefit seems considerably lower for the other groups of high-risk patients.

Results of systematic second-look surgery in patients at high risk of developing colorectal peritoneal carcinomatosis

OBJECTIVE

The aim of this prospective study was to analyze the impact of second-look surgery in an attempt to treat peritoneal carcinomatosis (PC) at an early stage in a series of patients at high risk of developing PC from colorectal cancer.

BACKGROUND

The prognosis of colorectal PC has recently been improved with hyperthermic intraperitoneal chemotherapy (HIPEC) after complete cytoreductive surgery (CCRS), and could be further improved if PC could be treated at an early stage. But, currently, the diagnosis of early PC is not accessible to imaging.

PATIENTS AND METHODS

From 1999 to 2006, 29 patients without any sign of recurrence on imaging studies underwent second-look surgery 13 months after resection of the primary tumor. Patients were selected according to primary tumor-associated criteria: resected minimal synchronous macroscopic PC (n = 16), synchronous ovarian metastases (n = 4), perforated primary tumor (n = 9).

RESULTS

PC was found and treated with CCRS plus HIPEC in 16 of 29 (55%) cases, corresponding to 10 of 16 patients with initial PC, 3 of 4 patients with synchronous ovarian metastases and 3 of 9 patients with a perforated primary tumor. There was no postoperative mortality, and morbidity (grade III/IV) occurred in 14% of cases. After a median follow-up of 27 months (range, 6-96), 8 of 16 patients treated with CCRS and HIPEC are free of disease, 4 relapsed in the peritoneum, and 4 developed isolated visceral metastases.

CONCLUSION

Performing second-look surgery at 1 year in selected patients at high risk of developing PC allowed the early detection and treatment of PC in 55% of cases. Our preliminary results have encouraged us to pursue this strategy and to evaluate it in a prospective multicenter trial.

Intraperitoneal hyperthermic chemotherapy for peritoneal surface malignancy: current status and future directions

Natural history studies have shown that peritoneal carcinomatosis is uniformly fatal, with a median survival in the range of approximately 6 months. For more than a decade, a handful of centers have pursued aggressive intraperitoneal cytoreductive surgery combined with intraperitoneal hyperthermic chemotherapy as an alternative approach to this disease. Strict selection criteria, variation in intraperitoneal chemotherapy, and the vagaries of what represents "cytoreductive surgery" make many of our colleagues, particularly those in medical oncology, reticent to refer patients for such an aggressive therapy. This article establishes a conceptual framework for understanding the role of intraperitoneal hyperthermic chemotherapy in the treatment of peritoneal surface malignancy. This procedure continues to make advancements in the oncological community despite formidable challenges. The advancement of centers of excellence and the initiation of further phase II trials will help to define the optimal treatment approach for peritoneal carcinomatosis.

The rationale of perioperative intraperitoneal chemotherapy in the treatment of peritoneal surface malignancies

In summary, the use of perioperative intraperitoneal chemotherapy is a rational and scientifically sound treatment option for patients with peritoneal carcinomatosis. By delivering chemotherapeutic agents directly into the peritoneal cavity in the perioperative period, after cytoreductive procedures resulting in minimal residual tumor load, the cytotoxicity, efficacy, and safety of these agents can be maximized. The use of this treatment strategy in the intraoperative or perioperative period ensures that the efficacy of the chemotherapeutic agents is not reduced by limitations of abdominal compartmentalization and scarring. Treating patients under hyperthermic conditions may confer an additional benefit. Although the use of perioperative chemotherapy or hyperthermic intraperitoneal chemotherapy is not yet part of the standard of care for the treatment of advanced abdominal malignancies, both basic science and clinical investigations have confirmed the validity of these regimens. Further clinical studies in a cooperative group setting are necessary to prove the efficacy of perioperative intraperitoneal chemotherapy in both the treatment and prevention of peritoneal surface malignancy.

Intérêt des lavages abdominaux pour la prévention de l’ensemencement néoplasique péritonéal

Spontaneous or iatrogenous peritoneal seeding is responsible for locoregional recurrent cancer or peritoneal carcinomatosis. Few surgeons are used to wash the abdominal cavity to prevent peritoneal seeding. But experimentally, washing is not able to dislodge or destroy tumour cells adherent to the peritoneum or to the surgical wounds. The antitumoral effect of abdominal washing is increased by addition of antiseptics or anti-adherent agents.

Intraperitoneal chemohyperthermia: rationale, technique, indications, and results

Intraperitoneal chemohyperthermia (IPCH) is a loco-regional treatment for intraperitoneal malignancies. This ultra-radical treatment combines complete cytoreduction of macroscopic peritoneal disease preceding perioperative intraperitoneal perfusion of a chemotherapeutic drug heated to 42 degrees to 44 degrees to treat microscopic residual disease. At present time, this approach is mainly indicated for isolated limited peritoneal carcinomatosis (PC) of colorectal origin and for treatment of low-grade pseudomyxoma peritonei. In selected patients, IPCH may lead to 27% five-year overall survival in cases of PC, and as high as 86% five-year survival in cases of pseudomyxoma peritonei. In the near future, this approach will become the standard treatment for selected cases of PC.

Curative treatment of peritoneal carcinomatosis arising from colorectal cancer by complete resection and intraperitoneal chemotherapy

BACKGROUND

Peritoneal carcinomatosis (PC) is fatal, despite standard systemic chemotherapy. A new approach that combines maximal surgery with maximal regional chemotherapy has potential to cure selected patients who have colorectal PC. The authors have reported the oncologic results of this combined treatment.

METHODS

The authors performed a retrospective study of 64 patients who had PC arising from colorectal adenocarcinomas, 19 (29.6%) of whom also had other metastases. These patients were treated by complete resection of all detectable tumors and by a 5-day course of early intraperitoneal chemotherapy (EPIC) with mitomycin C, then by 5-fluorouracil (n = 37), or by intraoperative intraperitoneal chemohyperthermia (IPCH) with mitomycin C, alone or combined with cisplatin (n = 27), in 2 separate trials. In the trial of IPCH, aimed at selecting the most reliable procedure in terms of spatial diffusion and thermal homogeneity, the 27 patients were treated with 7 different procedures. The extent of PC was assessed precisely by using a peritoneal index. The median follow-up period for the entire patient population was 51.7 months.

RESULTS

The postoperative mortality and morbidity rates were 9.3% and 54.6%, respectively. Most severe complications occurred in patients who required extensive cytoreductive surgery. Global and disease-free survival rates were respectively 60.1% and 54.7% at 2 years and were 27.4% and 18.4% at 5 years. Results were significantly better (P = 0.04) when patients were metastasis-free (apart from PC) and when the peritoneal index was lower than 16 (P = 0.005). IPCH seemed to be more effective than EPIC for treatment of PC.

CONCLUSION

This treatment plan, which combined maximal surgery with maximal regional chemotherapy, cured approximately 25% of patients. This strategy was mainly applicable to patients with limited intraperitoneal cancer volume and no extraperitoneal involvement. IPCH proved to be more effective than EPIC but more difficult to use correctly. Future results should improve through routine use of the optimal hyperthermia procedure, with improvements in the composition of instillate, better patient selection, and the reduction in the rate of complications that occurs with physician experience.

Curative treatment of peritoneal carcinomatosis arising from colorectal cancer by complete resection and intraperitoneal chemotherapy

BACKGROUND

Peritoneal carcinomatosis (PC) is fatal, despite standard systemic chemotherapy. A new approach that combines maximal surgery with maximal regional chemotherapy has potential to cure selected patients who have colorectal PC. The authors have reported the oncologic results of this combined treatment.

METHODS

The authors performed a retrospective study of 64 patients who had PC arising from colorectal adenocarcinomas, 19 (29.6%) of whom also had other metastases. These patients were treated by complete resection of all detectable tumors and by a 5-day course of early intraperitoneal chemotherapy (EPIC) with mitomycin C, then by 5-fluorouracil (n = 37), or by intraoperative intraperitoneal chemohyperthermia (IPCH) with mitomycin C, alone or combined with cisplatin (n = 27), in 2 separate trials. In the trial of IPCH, aimed at selecting the most reliable procedure in terms of spatial diffusion and thermal homogeneity, the 27 patients were treated with 7 different procedures. The extent of PC was assessed precisely by using a peritoneal index. The median follow-up period for the entire patient population was 51.7 months.

RESULTS

The postoperative mortality and morbidity rates were 9.3% and 54.6%, respectively. Most severe complications occurred in patients who required extensive cytoreductive surgery. Global and disease-free survival rates were respectively 60.1% and 54.7% at 2 years and were 27.4% and 18.4% at 5 years. Results were significantly better (P = 0.04) when patients were metastasis-free (apart from PC) and when the peritoneal index was lower than 16 (P = 0.005). IPCH seemed to be more effective than EPIC for treatment of PC.

CONCLUSION

This treatment plan, which combined maximal surgery with maximal regional chemotherapy, cured approximately 25% of patients. This strategy was mainly applicable to patients with limited intraperitoneal cancer volume and no extraperitoneal involvement. IPCH proved to be more effective than EPIC but more difficult to use correctly. Future results should improve through routine use of the optimal hyperthermia procedure, with improvements in the composition of instillate, better patient selection, and the reduction in the rate of complications that occurs with physician experience.

Cancer and laparoscopy, experimental studies: a review

OBJECTIVE

To review the experimental studies on laparoscopy and cancer and to propose guidelines for the clinical management of gynecologic cancer.

METHODS

The literature in MEDLINE was searched from January 1992 to December 1998 using the terms 'cancer', 'laparoscopy' and 'experimental or animal study'. Cross-referencing identified additional publications. Abstracts and letters to the editor were excluded. All the relevant papers were reviewed.

RESULTS

Depending on the model used, controversial results have been reported on the incidence of trocar site metastasis when comparing CO(2) laparoscopy and laparotomy. In contrast, the following conclusions can be proposed: (i) tumour growth after laparotomy is greater than after endoscopy; (ii) tumour dissemination is worse after CO(2) laparoscopy than after laparotomy; (iii) some of the disadvantages of CO(2) laparoscopy may be treated using local or intravenous treatments or avoided using other endoscopic exposure methods, such as gasless laparoscopy.

CONCLUSIONS

The laparoscopic treatment of gynecologic cancer has potential advantages and disadvantages, and may only be performed in prospective clinical trials. The risk of dissemination appears high when a large number of malignant cells are present. Adnexal tumours with external vegetations, and bulky lymph nodes should be considered as contra-indications to CO(2) laparoscopy.

[Treatment of peritoneal carcinomatosis using complete excision and intraperitoneal chemohyperthermia. A phase I-II study defining the best technical procedures]

OBJECTIVES

The complete or quasi complete resection of peritoneal carcinomatosis (PC) followed with IPCH is potentially able to cure some patients with a disease confined to the peritoneum. The aim of this prospective phase I-II study was to elaborate an efficient IPCH procedure with a good thermal homogeneity and a good spatial diffusion, which should be reproductible (and so standardizable and exportable), and to appreciate its tolerance and its carcinologic impact.

PATIENTS AND METHODS

Seven IPCH procedures were successively tested in 32 patients (for a total of 35 IPCH); each of these were tested in at least four patients before being modified for technical or tolerance reason. Five of them were followed with an immediate postoperative intraperitoneal chemotherapy (IPIC) lasting four days. Thermal homogeneity was measured with six thermal probes situated in different places inside the abdominal cavity. Spatial diffusion was studied in the last patients by adding methylene blue in the IPCH liquid. The precise extent of the PC was reported, for each intra-abdominal region, and scored with a peritoneal index (ranging from 1 to 39). The mean follow-up was 23.85 months for the series.

RESULTS

Procedures with the closure of the abdomen were not efficient: thermal homogeneity was almost satisfactory when only the skin was closed, but these 'closed' procedures did not permit the treatment of all the risky surfaces. The peritoneal cavity 'expander' did not permit the treatment of the parietal wound, and an undetermined amount of the perfusion oozed out at its periphery. The open technique by tracking the skin upwards was the best one. Death occurred in three patients (9.4%), and complications occurred in 24 patients (75%) during the postoperative course. Intra-abdominal complications were significantly correlated (P = 0.02) with the peritoneal index (scoring the extent of the PC). The two year survival rate was 60%, and PC did not recur in 50% of the patients.

CONCLUSION

An efficient and reproducible procedure for IPCH was defined: an open procedure with an upwards traction of the skin. The post-IPCH IPIC was abandoned because it did not treat all the risky peritoneal surfaces. Patients with an extended PC and with extraperitoneal localization did not seem to have benefited from this therapeutic approach. Progress is needed in the chemotherapeutical procedure and indications must be more finely defined.

Principles of oncologic abdominal surgery

The principles of abdominal oncologic surgery parallel the general principles of all types of oncologic surgery with some variations peculiar to the abdomen. Due to the presence of multiple organ systems within the abdominal cavity, many types of cancer can develop. The surgeon must be prepared to perform several different abdominal procedures depending on the organ system involved and the extent of the cancer. The surgeon as oncologist must be aware of the tumor type, its expected behavior, and current treatment options. This article describes the principles of performing cancer surgery, including preparation for abdominal exploration, methods to facilitate tumor removal, and ways of avoiding tumor recurrence.

The potential role of integrin receptor subunits in the formation of local recurrence and distant metastasis by mouse breast cancer cells

BACKGROUND

The mechanisms by which surgical injury fosters tumor growth are examined.

METHODS

TA3Ha mouse breast tumor line and its subline (TA3AD) differing in their metastatic abilities as tested by two models were used. In model a, TA3Ha/TA3AD tumors were grown in the mammary fat pads of mice and then surgically removed with a curative intent. In model b, TA3Ha/TA3AD cells were injected intravenously into mice subjected to liver or spleen wedge resection. Frequency of tumor formation at various sites was assessed. Expression of integrin, immunoglobulin, and proteoglycan cell adhesion receptors on TA3Ha and TA3AD cells was examined by flow cytometry. The roles of these receptors in metastasis were examined by blocking them by selected ligands and/or antibodies.

RESULTS

Frequencies of local recurrence and axillary metastasis after surgical resection, were 43% (32/74), and 37% (27/74) with TA3Ha tumors and 4% (1/29) at both sites with TA3AD tumors. Tumors at surgically injured spleen and the liver were seen in 75% (141/189) and 45% (107/240) of the mice with TA3Ha cells and in 8% (3/38) and 10% (4/42) of the mice with TA3AD cells. alpha 5 and CD44 receptors were expressed by TA3Ha cells but not by TA3AD cells. Other receptors examined were similarly expressed by both cell lines. Blocking of alpha 5 receptor by fibronectin reduced tumor implantation in a dose-dependent manner.

CONCLUSIONS

The data suggest a correlation among the ability to implant at surgically injured sites, to form local recurrence, and to express the fibronectin receptor subunit.

Strategies to decrease the incidence of intra-abdominal recurrence in resectable gastric cancer

Two main approaches are suggested to improve treatment results in resectable gastric cancer: extended lymphadenectomy and adjuvant antitumour therapy. Progress is to some extent stalled by the perception of gastric cancer as a pathophysiologically uniform disease; it has been demonstrated, however, that there are variants of gastric cancer associated with predominantly intra-abdominal spread or with haematogenous metastases. Recent clinicopathological studies have provided information about the mechanisms of this metastatic diversity. A review of clinical trials suggests that no single method of treatment can efficiently address all variants of gastric cancer spread, but new treatment strategies may be based on defining the pathophysiological variant of gastric cancer and selecting adjuvant therapy according to the most probable mode of tumour spread. Treatment should start with surgery which includes a 'reasonably' extended lymphadenectomy aimed at achieving an increased rate of curative resection and more accurate staging. Risk factors for peritoneal spread of tumour require the perioperative use of intraperitoneal chemotherapy. Subsequent adjuvant therapy may be indicated in patients at high risk of further cancer spread or occult metastases, as determined by pathological examination of the resected specimen.

Role of cytokines and growth factors in promoting the local recurrence of breast cancer

The pathogenesis of local recurrence in breast cancer is not well understood. Breast-conserving surgery is particularly prone to local recurrence as it leaves behind breast tissue that may harbour occult cancer, and lends itself to enhanced intraoperative shedding of cancer cells due to narrower resection margins and transection of lymphatic channels. A review of clinical breast cancer studies as well as experimental research strongly suggests that these persisting cancerous cells are unlikely to develop into clinically evident disease if their environment remains unstimulated. However, an inordinately high local recurrence rate occurs at the surgical scar, and such recurrence must be triggered by the release of growth factors and cytokines into the healing wound. These factors can stimulate any available cancer cells which express the proper growth factor receptors. Perioperative strategies to neutralize this tumour cell-growth factor interaction should maximize local control.

Principles of surgical oncology

Surgical treatment of cancer has many advantages over other treatment modalities. The principles of defining the goal of surgery, surgical planning, surgical technique, surgical margins, and patient aftercare are reviewed. Special attention is devoted to tumor seeding and obtaining adequate margins. Incorporation of biologic behavior and stage of disease into the surgical plan are paramount to the successful implementation of surgery in cancer treatment.

Is there a role for clinical prognostic factors in staging patients with colorectal cancer?

The clinician treating colorectal cancer (CRC) should be able to predict which patients will live and which will die from their tumor. Many prognostic variables, significant in retrospective analyses, are never formally used in staging. The resultant imperfection of clinical predictions of survival are probably directly related to the relative inaccuracy of the staging system, a system inevitably dependent entirely on pathologic criteria. Potentially valuable clinical variables, sometimes associated with better or worse outcome despite the pathologic stage of disease, could improve the accuracy of prediction. Evolution to better clinico-pathologic staging systems would also help to better stratify patients in prospective randomized trials of new adjuvant therapeutic modalities.