Surgical management of locally advanced adenocarcinoma of the rectum

The safety of an MRI simulation-guided boost after short-course preoperative radiotherapy for unresectable rectal cancer (SUNRISE): interim analysis of a randomized phase II trial

PURPOSE

The safety of an MRI simulation-guided boost after short-course preoperative radiotherapy (SCPRT) for unresectable rectal cancer is assessed with a planned interim analysis.

METHODS AND MATERIALS

Patients diagnosed with clinical stage T3-4 or regional lymph node-positive disease with positive mesorectal fascia or T4b disease evaluated by pelvic MRI were randomly assigned to the SCPRT-boost group (25 Gy in 5 fractions plus 4 Gy delivered to the gross tumor volume, followed by four cycles of chemotherapy) or preoperative chemoradiotherapy group (50 Gy in 25 fractions with concurrent chemotherapy). Then, patients received total mesorectal excision surgery after preoperative treatment. The primary endpoint was the R0 resection rate. The interim analysis was performed when 42 patients completed their assigned treatments.

RESULTS

From October 2018 to November 2019, a total of 43 patients were enrolled, and 42 patients were included in the interim analysis. During preoperative therapy, grade 3 or above toxicities were observed in 10/21 (47.6%) patients in the experimental group, and 4/21 (19.0%) patients in the control group. A total of 17 (81.0%) and 13 (61.9%) patients in the experimental group and control group underwent surgery, respectively. Overall, 65.1% of the patients achieved R0 resection in the intention-to-treat analysis. Surgery-related adverse complications were observed in 2 patients (11.8%) in the experimental group and 1 patient (7.7%) in the control group.

CONCLUSION

Our results show that the toxicity of an MRI simulation-guided boost after SCPRT for unresectable rectal cancer is acceptable. Thus, this clinical trial will be continued as planned.

Outcomes of Partial or Total Cystectomy in Advanced Colon Cancer with Suspected Bladder Invasion-Our 8-Year Experience and Literature Review

PURPOSE

Advanced colon cancers with bladder invasion pose a heavy burden and challenge towards patients and surgeons. Herein, we report our series with regards to operative and oncological outcomes in our 8 years of experience.

METHODS

All patients with advanced colonic tumours and suspected bladder invasion being operated from 2012 to 2020 were included. The histological findings, clinical and oncological outcomes were evaluated.

RESULTS

Twenty-two patients were included. Partial cystectomy was performed in 17 of them (77%). No neoadjuvant treatment was prescribed. All preoperative computed tomography (CT) scan showed bladder invasion or colovesical fistula. True tumour invasion to bladder (T4b disease) was confirmed in 17 patients (77%) by histopathology. The 3-year overall survival and recurrence rates were 82% and 9%, respectively.

CONCLUSION

En bloc resection of colonic tumour with adherent bladder in advanced colon cancers can achieve a good operative and oncological outcome without neoadjuvant therapy. The relatively low concordance rate between preoperative CT scan and final histopathology may limit the benefit of routine administration of neoadjuvant therapy as it may overtreat and delay subsequent oncological treatment of our patients with possible added morbidity.

Adenocarcinoma of the Colon Disguised as Abdominal Wall Abscess: Case Report and Review of the Literature

Introduction

Abdominal wall invasion by cancerous cells arising from the colon with an overlying secondary infection that presents as an abdominal wall abscess has been encountered previously, but such a symptom is rarely the first presentation of colon cancer. There are very few cases reported in the literature.

Case Presentation

In this case report, we present a case of a 66-year-old male presenting with abdominal wall abscess that was refractory to treatment. The patient later was found to have an abdominal wall invasion by an underlying colonic carcinoma.

Conclusion

The purpose of this review is to set forth the proper approach when encountering such cases and emphasize on the significance of keeping a high index of suspicion. We also highlight the need for utilizing proper diagnostic imaging modalities prior to invasive intervention.

Clinical review: surgical management of locally advanced and recurrent colorectal cancer

AIM

Recurrent and locally advanced colorectal cancers frequently require en bloc resection of involved organs to achieve negative margins. The aim of this review is to evaluate the most current literature related to the surgical management of locally advanced and recurrent colorectal cancer.

METHODS

A literature review was performed on the electronic databases MEDLINE from PubMed, EMBASE and the Cochrane library for publications in the English language from January 1993 to July 2013. The MeSH search terms 'locally advanced colorectal cancer', 'recurrent colorectal cancer' and 'surgical management' were used.

RESULTS

A total of 1,470 patients with recurrent or locally advanced primary colorectal cancer were included in 22 studies. Surgical removal of the tumour with negative margins (R0) offers the best prognosis in term of survival with a 5-year survival of up to 70 %. MVR is needed in approximately 10 % with the most commonly involved organ being the bladder. The mean post-operative morbidity is 40 %, mainly relating to superficial surgical site infection, pelvic collections and delayed wound healing. Most patients will undergo radiotherapy and/or chemotherapy pre- or post-operatively. The mean 5-year overall survival for R0 resection is 50 % for recurrent and locally advanced primary tumours while survival following R1 or R2 is 12 and <5 %, respectively.

CONCLUSION

Multimodal therapy and extended surgery to achieve clear margins offers good prognosis to patients with recurrent and locally advanced colorectal cancers.

Laparoscopic resection with intraoperative radiotherapy for local advanced rectal cancer: a preliminary case report

OBJECTIVE

To report the feasibility of laparoscopic resection with intraoperative radiotherapy for local advanced rectal cancer in an Asian man.

PATIENT AND METHODS

A 55-year-old man with adenocarcinoma of the rectum presented at Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China. The tumor, with a size of 5 × 5 cm, was located 3 cm from the anus and covered a circular area around approximately two-thirds of the bowel. The carcinoembryonic antigen level was 29.86 ng/mL; a nodule was detected, but no distant metastasis was detected. Preoperative staging was T4N1M0. After the patient signed the consent form, laparoscopic resection with intraoperative radiotherapy was performed.

RESULTS

The operation time was about 180 minutes, intraoperative blood loss was 100 mL, and postoperative hospital stay was 8 days. The patient had no postoperative complications. conclusions: Performance of laparoscopic resection with intraoperative radiotherapy for local advanced rectal cancer is feasible in selected patients.

Results after multivisceral resections of locally advanced colorectal cancers: an analysis on clinical and pathological t4 tumors

BACKGROUND

Locally advanced colorectal cancers are best treated with multivisceral resections. The aim of this study is to evaluate early and late results after multivisceral resections.

METHODS

All patients operated for primary colorectal cancer between 2001 and 2010 were -reviewed. These were compared within the patients underwent single organ and multivisceral resections: demographics, tumor and procedure related parameters, perioperative results, early oncological outcomes and 5-year survival.

RESULTS

A total of 354 patients (59.6 ± 13.8 years old, 210 [59.3%] males) were abstracted. Ninety (25.4%) patients underwent multivisceral resections for clinical T4 tumors and en-bloc R0 resection was achieved in 82 (91.1%). Only 31 (34.4% and 8.8% of clinical T4 and all cancers, respectively) cases had actual adjacent organ invasions (pT4). Males (20%) had lower risk for locally advanced tumors than females (33.3%) (p < 0.05). PT4 cancers were more common, if the clinical T4 tumor is located in the colon (48.8% vs 21.3%; p < 0.01). Laparoscopy was seldom initiated and the risk of conversion was higher in clinical T4 tumors (p < 0.05). The rates of sphincter-saving procedures were not different. Operation time, bleeding and transfusion requirements increased when multivisceral resections were necessitated (p < 0.05), but hospital stay, complications and 30-day mortality rates were similar. The 5-year survival rates were identical (p > 0.05).

CONCLUSIONS

Clinical T4 tumors are not rare and more common in women. An actual invasion (pT4) may be observed in one third of all clinical T4 tumors, and more frequent in colon cancers. An en-bloc, R0, multivisceral resection may be achieved in most cases. Multivisceral resections do not alter the rates of sphincter-saving procedures, morbidity and 30-day mortality; do not worsen survival but increase operation time, intraoperative bleeding and perioperative transfusion requirements.

En bloc urinary bladder resection for locally advanced colorectal cancer: a 17-year experience

BACKGROUND AND OBJECTIVES

En bloc bladder resection is often required for treating colorectal cancer with suspected urinary bladder invasion. Our aim was to review our institutional experience in en bloc resection of locally advanced colorectal cancer involving the urinary bladder over a period of 17 years.

METHODS

The hospital records of 72 patients with locally advanced colorectal cancer who underwent en bloc urinary bladder resection at our institution between July 1987 and December 2004 were retrospectively reviewed. Clinical and oncologic outcomes were evaluated.

RESULTS

The mean duration of follow-up was 64.3 months. Genuine tumor invasion into the urinary bladder was confirmed in 34 patients (47%) by histopathology. Forty patients (56%) underwent primary closure of the urinary bladder, while 32 patients (44%) required various kinds of urologic reconstructive procedures. Operative mortality occurred in four patients (6%). The overall postoperative morbidity rate was significantly higher in patients undergoing urologic reconstruction (81% vs. 45%, p = 0.002) when compared to that in patients undergoing primary closure. This was mostly attributable to significantly higher rates of urinary anastomotic leak (21.9% vs. 0%, p = 0.002) and urinary tract infection (50% vs. 18%, p = 0.003) in the urologic reconstruction group. For the 57 patients (79%) who underwent curative resection, the 5-year overall survival rate was 59%, and the local recurrence at 5 years was 15%. Both parameters were not significantly affected by the presence of pathologic bladder invasion or the extent of surgical procedures.

CONCLUSIONS

En bloc bladder resection for locally advanced colorectal cancer involving the urinary bladder can produce reasonable long-term local control and patient survival.

Ontogenetic anatomy of the distal vagina: relevance for local tumor spread and implications for cancer surgery

OBJECTIVE

We have suggested to base cancer surgery on ontogenetic anatomy and the compartment theory of tumor permeation in order to improve local tumor control and to lower treatment-related morbidity. Following the validation of this concept for the uterine cervix, proximal vagina and vulva, this study explores its applicability for the distal vagina.

METHODS

Serial transverse sections of female embryos and fetuses aged 8-17 weeks were assessed for the morphological changes in the region defined by the deep urogenital sinus-vaginal plate complex. Histopathological pattern analysis of local tumor spread was performed with carcinomas of the lower genital tract involving the distal vagina to test the compartment theory.

RESULTS

Ontogenetically, the female urethra, urethrovaginal septum, distal vagina and rectovaginal septum represent a morphogenetic unit derived from the deep urogenital sinus-vaginal plate complex. Herein, the posterior urethra, the urethrovaginal septum and the distal vagina form a distinct subcompartment differentiated from the dorsal wall of the urogenital sinus. From 150 consecutive patients with distal vaginectomy as part of their surgical treatment 26 carcinomas of the lower genital tract had infiltrated the distal vagina. All 22 tumors involving the ventral wall invaded the urethra/periurethral tissue. Of the five carcinomas involving the dorsal wall none invaded the rectum/mesorectum.

CONCLUSION

The pattern of local tumor permeation of lower genital tract cancer in the distal vagina can be consistently explained with ontogenetic anatomy and the compartment theory.

Contiguous invasion per se does not affect prognosis in colon cancer

BACKGROUND

Locally advanced colon cancer can result in serious clinical conditions unless treated appropriately. The aim of this study was to examine the feasibility of en bloc resection and the significance of depth of invasion by analyzing the outcomes of the procedure in colon cancer invading adjacent organs.

METHODS

Outcomes of 65 locally advanced colon cancer patients who underwent en bloc resections for contiguous invasion were compared with 285 pT3 colon cancer patients.

RESULTS

En bloc combined resection was performed in 75 patients and 10 (13.3%) of them showed no true malignant infiltration into adjacent organs. In both pT3 and pT4 groups, there was no significant difference in major postoperative complications or mortality. The survival rate of pT4 group was similar to that of pT3 group (5-year rate, 64.0% vs. 72.7%; P = 0.287). In multivariate analysis, lymph node metastasis, lymphovascular infiltration, and perineural invasion were independently associated with patient survival.

CONCLUSIONS

The prognosis of colon cancer, even in locally advanced cases, is mainly correlated with nodal status rather than depth of invasion. Therefore, en bloc combined resection in locally advanced colon cancer invading adjacent organs can improve survival as well as local control with acceptable morbidity and mortality.

Can unresectable colorectal cancer be cured?

A multimodality regimen that includes EBRT, chemotherapy, maximal surgical resection, and IORT, when used in patients with initially unresectable primary colon or rectal adenocarcinoma, is associated with excellent long-term local control, and a 5-year overall survival of 52%. Distant metastases account for most treatment failures, occurring in roughly 50%. Treatment-related morbidity is high, with a long-term complication rate that approaches 50%. These results suggest that selected patients with advanced unresectable disease benefit from an aggressive approach. Additional effort needs to focus on reducing the rate of systemic failure with more effective chemotherapy regimens and minimizing the frequency of long-term procedural complications.

Unresectable colorectal cancer can be cured with multimodality therapy

OBJECTIVE

The aim of this study was to determine in what manner aggressive external beam radiotherapy (EBRT), chemotherapy, surgical resection, and intraoperative radiotherapy (IORT) impact relapse and survival in patients with locally unresectable primary colorectal cancer.

SUMMARY BACKGROUND DATA

Patients with colorectal cancer fixed to critical structures (eg, IVC and pelvic sidewall) are considered locally "unresectable" for cure and treated with palliative therapy.

METHODS

One hundred forty-six patients (65% males) with locally unresectable colon (40) and rectal (106) cancer were treated with EBRT, chemotherapy, surgical resection, and IORT. Final surgical margins were close, but negative in 100 patients (68%), microscopically positive in 28 (19%), and grossly positive in 18 (13%). Kaplan-Meier method was used to visualize survival and relapse curves; groups were compared using the log-rank test.

RESULTS

Median overall survival was 3.7 years. Median overall survival (years) favored patients with age <58 (7.6 vs. 3.6; P = 0.0012), those receiving adjuvant chemotherapy (9.4 versus 3.9; P = 0.0019), and those with negative or microscopic margins (6.3 vs. 1.9; P = 0.0006). There were no perioperative deaths. Fifteen complications occurred in 12 patients (8%) within 30 days of surgery/IORT. One hundred nineteen long-term complications occurred in 77 patients (53%), most commonly peripheral neuropathy (19%), bowel obstruction (14%), and ureteral obstruction (12%).

CONCLUSIONS

Aggressive multimodality therapy for locally unresectable primary colorectal cancer results in excellent local disease control and a 5-year disease-free and overall survival rate of 43% and 52% respectively with no operative mortality and acceptable perioperative morbidities.

Prognostic factors after preoperative irradiation and surgery for locally advanced rectal cancer

AIMS

The experience of preoperative irradiation in clinically locally advanced rectal cancer for the period 1991-2003 is reported. Prognostic factors for survival and recurrence, and parameters for obtaining a free circumferential margin were evaluated.

METHODS

A prospective cohort study of 204 M0 patients given >45 Gy preoperatively (median age 66 years; 29% women; tumour level <16 cm from the anal verge).

RESULTS

Multivisceral and/or pelvic wall resections were performed in 61% of the patients. R0, R1 and R2 resections were achieved in 74%, 21% and 5%. Five-year survival was 52% for all patients, 60% for R0 resections, 31% for R1 and 0% for R2. The calculated 5-year recurrence rates were 13% for R0 resections and 24% for R1 resections (p<0.035). R-stage, N-stage, age, type of rectal resection and pelvic wall resection remained significant in Cox multivariate analysis for survival. Regarding local recurrence, the following parameters were independent: N-stage, carcinoembryonic antigen (CEA) response and pelvic wall resection. Medium high tumour level and reduced histopathological differentiation are important individual factors that seem to predict increased risk for not obtaining a R0 resection.

CONCLUSIONS

After preoperative irradiation and surgery, about 50% of the patients with locally advanced rectal cancer without overt metastases (M0) can be cured.

Local involvement of the urinary bladder in primary colorectal cancer: outcome with en-bloc resection

BACKGROUND

Colorectal cancers that adhere to the urinary bladder require en-bloc partial or total cystectomy to achieve negative tumor margins.

METHODS

This prospective study evaluated the outcome of combined bladder resection for carcinoma of the colon or rectum at a unit specializing in gastrointestinal cancer.

RESULTS

Patients (n = 63) with colorectal tumors adherent to the bladder at operation and without distal metastases were followed. Fifty-eight patients (92%) had tumors of the sigmoid colon or upper rectum. Operative morbidity and mortality rates were 18% and 1.5%, respectively. Histological staging demonstrated bladder adherence in 46% (29/63) and invasion in 54% (34/63). Overall disease-specific survival was 54% with a mean follow-up of 7.6 years (range 5-12). Five-year survival for margin-negative patients was 72% (26/36) and 27% (4/15) for node-negative and -positive tumors, respectively. The bladder was closed primarily in 48 patients and reconstructed by enterocystoplasty in 5, with 10 patients requiring urinary diversion.

CONCLUSIONS

En-bloc bladder resection for adherent or invading tumors of the colon and rectum achieves good local control, but an infiltrative extravesical margin denotes poor prognosis. The potential for cure in completely excised node-negative tumors is good. Bladder reconstruction is achievable in most patients.

Local Involvement of the Urinary Bladder in Primary Colorectal Cancer: Outcome with En Bloc Resection

BACKGROUND

Colorectal cancers that adhere to the urinary bladder require en bloc partial or total cystectomy to achieve negative tumor margins.

METHODS

This prospective study evaluated the outcome of combined bladder resection for carcinoma of the colon or rectum at a unit specializing in gastrointestinal cancer.

RESULTS

Patients (n = 63) with colorectal tumors adherent to the bladder at operation and without distal metastases were followed. Fifty-eight patients (92%) had tumors of the sigmoid colon or upper rectum. Operative morbidity and mortality rates were 18% and 1.5%, respectively. Histological staging demonstrated bladder adherence in 46% (29/63) and invasion in 54% (34/63). Overall disease-specific survival was 54%, with a mean follow-up of 7.6 (range 5-12) years. Five-year survival for margin negative patients was 72% (26/36) and 27% (4/15) for node negative and positive tumors, respectively. The bladder was closed primarily in 48 patients and reconstructed by enterocystoplasty in five, with ten patients requiring urinary diversion.

CONCLUSIONS

En bloc bladder resection for adherent or invading tumors of the colon and rectum achieves good local control, but an infiltrative extravesical margin denotes poor prognosis. The potential for cure in completely excised node negative tumors is good. Bladder reconstruction is achievable in most patients.

Surgical treatment of primary locally advanced rectal cancer in Norway

AIMS

Most reports on locally advanced rectal cancer come from specialized centres, with a selected patient material. The purpose of this study was to examine the results after surgical treatment of patients with locally advanced rectal cancer at a population level.

METHODS

National cohort study of 896 patients undergoing surgery for a locally advanced primary adenocarcinoma of the rectum from November 1993 to December 2001.

RESULTS

Surgery with resection was undertaken in 724 patients and 172 patients underwent palliative procedures. Of 557 patients treated for cure, a R0 resection was achieved in 342 (61%). In a multivariate analysis, pre-operative radiotherapy was the only factor with a positive association with R0 status (odds ratio 3.7, 95% confidence interval (CI) 2.1-6.4). Five-year local recurrence rates were 18% (CI 14-23) for R0 resections and 40% (CI 26-52) for R1 resections. Overall 5-year survival rate was 23%; for the group of patients with a R0 resection the survival rate was 49%.

CONCLUSION

The radical resection rate and survival rates in this national study were similar to those reported from specialized centres.

Surgical Treatment of Colon Cancer

Over 100,000 Americans are diagnosed each year with colon cancer and approximately 90% are treated surgically. Most undergo a curative intent resection, but 30 to 50 percent will have a recurrence of their disease. While much of the variability in outcomes depends on the stage of the disease and other tumor variables, it is now clear that surgeon variables such as caseload and training affect both local recurrence and patient survival. Operative techniques including laparoscopic and other minimally invasive procedures and surgical decisions including choice of operative procedure, management of cancer arising in polyps and treatment of metastatic disease affect outcomes. The role of postoperative surveillance for recurrence remains controversial.

The assessment of urinary function following extended lymph node dissection for colorectal cancer

AIMS

The aim of the current study is to demonstrate whether the effects of extended systematic lymph-node dissection (ESLND) on urinary dysfunctions differ from those of curative radical surgery (CRS) only for rectal cancer.

METHODS

We present data about our patients who underwent rectal resection for rectal cancer over 5 years. One hundred and seventy patients with rectal cancer were reviewed with respect to surgical procedures and post-operative urinary problems.

RESULTS

We performed CRS on 146 patients and CRS+ESLND on 24 patients, and analysed the incidence of post-operative urinary dysfunction in both groups. Urinary incontinence rates were 39 and 58%, urinary retention rates were 4 and 16%, for the patients from CRS group and CRS+ESLND group, respectively.

CONCLUSIONS

We conclude that the addition of ESLND to CRS does not increase the frequency of post-operative urinary dysfunction, apart from an increased risk of urinary retention.

Intraoperative radiotherapy in the multimodality approach to colorectal cancer

The addition of intraoperative radiotherapy (IORT) to the multimodality approach for the treatment of locally advanced and locally recurrent colorectal cancer seems to result in improvements in local control and long-term survival. Local control and survival are most likely in patients in whom a gross total resection is accomplished. Peripheral nerve is the dose-limiting structure for patients treated with IORT. Further improvements in local control require the addition of dose modifiers during external beam radiotherapy or IORT. Distant relapse remains problematic, and effective systemic therapy is necessary to significantly improve long-term survival.

Urinary tract involvement by colorectal cancer

PURPOSE

Involvement of the urinary tract by colorectal cancer is sufficiently rare to be encountered by an individual surgeon on an infrequent basis. The aim of this review is to highlight technical and oncologic issues that should be considered when dealing with complex colorectal cancer that involves the urinary tract.

METHODS

The relevant literature from 1975 to 2001 was identified using the MEDLINE database of the U.S. National Library of Medicine and reviewed. Because of the diversity of forms of presentation of urologic involvement, few randomized, controlled trials are available, with most evidence derived from retrospective studies.

RESULTS

Three distinct clinical situations in which the urinary tract may be affected by colorectal cancer were identified: involvement by primary colorectal cancer, involvement by recurrent cancer, and unexpected intraoperative findings of urinary tract involvement. Management strategies to identify and treat locally advanced primary or recurrent colorectal cancer involving the urinary tract improve survival with acceptable morbidity and mortality. Careful preoperative assessment of all patients with colorectal cancer will reduce unexpected identification of urinary tract invasion at the time of surgery. In patients in whom cure is not possible, endourologic techniques combined with judicious surgical resection can provide high-quality palliation. Optimal care of many of these conditions is facilitated by specialist urologic advice.

CONCLUSIONS

The wide spectrum of possible urinary tract involvement by colorectal cancer requires individual patient-specific and disease-specific consideration. The literature offers important guidelines that aid decision making and improve management of these challenging problems.

Results after rectal cancer resection with in-continuity partial vaginectomy and total mesorectal excision

BACKGROUND

Although sharp mesorectal excision reduces circumferential margin involvement and local recurrence, a concomitant partial vaginectomy may be required in women with locally advanced rectal cancer.

METHODS

Sixty-four patients requiring a partial vaginectomy during resection of primary rectal cancer were identified. Survival was determined by the Kaplan-Meier method, and distributions were compared by the log-rank test.

RESULTS

Locally advanced disease was reflected by presentation with malignant rectovaginal fistulae (n = 6) or cancers described as bulky or adherent/tethered to the rectovaginal septum (n = 32). Thirty-five patients received adjuvant radiation with or without chemotherapy. At a median follow-up of 22 months, 27 (42%) patients developed recurrent disease, with most of these occurring at distant sites. The 5-year overall survival was 46%, with a median survival of 44 months. The 2-year local recurrence-free survival was 84%. The crude local failure rate was 16% (10 of 64), and local recurrence was more common in patients with a positive as opposed to a negative microscopic margin (2 [50%] of 4 vs. 8 [13%] of 60, respectively). Positive nodal status had a significant effect on overall survival (P <.001).

CONCLUSIONS

Partial vaginectomy is indicated for locally advanced rectal cancers involving the vagina. The results are most favorable in patients with negative surgical margins and node-negative disease.

Multivisceral resection for locally advanced primary colon and rectal cancer: an analysis of prognostic factors in 201 patients

OBJECTIVE

To review a single-center experience with 201 multivisceral resections for primary colorectal cancer to determine the accuracy of intraoperative prediction of potential curability, to identify prognostic factors, and to examine the effect of surgical experience on immediate outcome and long-term results.

SUMMARY BACKGROUND DATA

Locally advanced colorectal cancer may require an intraoperative decision for en bloc resection of surrounding organs or structures to achieve complete tumor removal. This decision must weigh the risk of complications and death of multivisceral resection against a potential survival benefit. Little is known about prognostic factors and the influence of surgical experience on the outcome of multivisceral resection for colorectal cancer.

METHODS

Patients undergoing multivisceral resection for primary colon or rectal cancer between 1982 and 1998 were identified from a prospective database. Patients were followed up according to a standard protocol.

RESULTS

Multivisceral resection was performed in 201 of 2,712 patients with a median age of 64 years. Postoperative rates of complications and death in 201 patients were 33% and 7.5%, respectively. A potentially curative resection was possible in 130 of 201 patients (65%) and histologic tumor infiltration was shown in 44% of patients with curative resection. Intraoperative assessment of curability was unreliable. After curative resection, the local recurrence rate was 11% and the overall 5-year survival rate was 51%. Multivariate analysis identified intraoperative blood loss (relative risk 1.7-6.4, P <.001), age 64 years or older (RR 3.7; P <.001), and UICC stage as independent prognostic factors (RR 2.0; P =.009). No prognostic significance was found for histologic tumor infiltration, the number of resected organs, or surgical experience.

CONCLUSIONS

Multivisceral resection is safe, and long-term survival after curative resection is similar to that after standard resection. Because palliative resections cannot be predicted accurately at the time of surgery, every effort should be made to achieve complete tumor resection. Major blood loss but not surgical experience per se is an independent prognostic factor.

Management of locally advanced rectal cancer

The treatment of rectal cancer typically involves a multidisciplinary approach. A minority of patients will have tumors that are full thickness, involve adjacent structures, or have metastatic disease to regional lymph nodes. The combination of adjuvant therapy and surgical resection is the mainstay of treatment for locally advanced carcinoma of the rectum. This article will review the role of adjuvant chemotherapy and radiotherapy in patients with high risk tumors. The operative considerations in advanced rectal cancers will be reviewed. In particular, the role of mesorectal excision and exenterative surgery will be discussed.

Surgical management of primary colorectal cancer

Surgery for potentially curable colorectal cancer most commonly involves resection of the primary tumor and regional lymph nodes. However, the site, extent and presentation of disease have an impact on surgical strategy and the use of combined modality therapy. For colon cancer, complex presentations such as obstructing or perforated colon cancer may influence surgical therapy, and issues pertaining to en bloc resection and oophorectomy remain unresolved. For rectal cancer, surgical management may range from local excision to radical resection. Extent of resection and relatively new operative techniques such as coloanal anastomosis with or without a colonic pouch reservoir are directed towards optimizing both oncologic and functional results.

Surgical management of locally recurrent rectal cancer

The surgical management of locally recurrent rectal cancer may involve major procedures and is not for the faint-hearted. Nevertheless, such treatment is preferable to chemotherapy and radiotherapy; the latter will fail over a period of months during which the patient is likely to experience intractable pain. Radical surgery offers good palliation and a better quality of life. Survival is prolonged by such operations which may be curative in up to one-third of patients. Nevertheless, surgeons must be realistic in their assessment of and discussions with patients.

Outcome of restorative perineal graciloplasty with simultaneous excision of the anus and rectum for cancer. A ten-year experience with 81 patients

PURPOSE

To review the complications, survival, and long-term functional outcome of patients with anorectal cancer who had restorative perineal graciloplasty (RPG) simultaneously with abdominoperineal resection (APR).

METHODS

Between 1985 and 1994, 81 patients underwent APR plus RPG. Gracilis muscles were then conditioned by electrostimulation, either intermittently or chronically. Thirtyseven surviving patients were followed for a mean of 78.6 months and were analyzed for long-term functional outcome of RPG.

RESULTS

Postoperative complications occurred in 30 patients (37 percent). Crude five-year survival rate was 58 percent, and five-year estimated cumulative probability of survival was 65 percent. There was no statistically significant difference for probability of survival and for probability of disease-free interval between uncomplicated and complicated patients. Fecal continence was obtained in 90 percent of patients.

CONCLUSION

RPG does not reduce the effectiveness of APR in the cure of cancer. Postoperative complications, though frequent, were not serious and resolved without sequelae. There was no statistically significant impact on the probability of survival and of disease-free interval by graciloplasty. Continence was achieved by most patients (90 percent) who underwent RPG simultaneously with APR.

Extended resections are beneficial for patients with locally advanced colorectal cancer

PURPOSE

Locally advanced colorectal cancer often requires extended resection to radically remove all tumor. This is the only chance for cure in these patients, but a higher complication rate would be expected. To evaluate the overall benefit for the patient, this study assesses morbidity and mortality as well as long-term survival of patients who underwent extended resection for a T3-T4 carcinoma.

METHODS

Two hundred twenty patients with locally advanced adenocarcinoma of the colorectum were included. One hundred fifty presented with a T3 and 70 with a T4 tumor. Eighty-three patients underwent extended resection. In 38 patients extended en bloc resection was performed because of inflammatory adherence mimicking infiltration. Thirty-three patients who underwent extended resections were over 70 years of age. There were no significant differences between the groups that underwent extended or nonextended resections in age, sex, stage, or grading.

RESULTS

pT4 lesions were significantly more frequent in the extended resection group than in the nonextended resection group. Mean survival was 44 months after extended resections and 45 months after nonextended resections. In the extended resection group there was no significant difference in mean survival between pT3 and pT4 stage patients within 46 and 38 months, respectively. In patients who underwent nonextended resections, however, there was a significant difference in mean survival within 48 months for pT3 and 28 for pT4 patients (P < 0.05). Postoperative morbidity and mortality were comparable between the extended resection group and the non-extended resection group. The presence of residual tumor influenced prognosis of patients significantly; R0 resections fared significantly better than patients who underwent R1 or R2 resections (55 and 51 to 14/12 and 23/8 months) (P < 0.01). Nodal stage and International Union Against Cancer stage were also significant determinants of prognosis. After extended resections mean survival morbidity and 30-day mortality in patients more than 70 years was similar to those less than 70 years.

CONCLUSION

Because extended resections can achieve comparable results in locally more advanced colorectal cancer as nonextended resections in less advanced cancer, an aggressive surgical approach is warranted.