Surgical treatment of metastatic colorectal adenocarcinoma

Follow-up after colorectal cancer surgery

Although most institutions offer some kind of follow-up to patients operated on for colorectal cancer, its value with respect to prolonged survival has been challenged. However, improved results of liver surgery and chemotherapy make it reasonable to assume that a follow-up programme leading to detection of more asymptomatic recurrences would result in improved survival. Liver metastases and extramural local recurrences are the most common secondary lesions and 5-year survival rates of about 30% are reported after radical resection. From these observations a survival benefit could be expected when follow-up is directed to these forms of recurrence. From six randomized studies, six comparative cohort studies and four meta-analyses it can be concluded that an intensive follow-up programme results in more recurrences being resected for cure and about a 10% higher 5-year survival rate compared with less intensive or no follow-up. However, the differences in the follow-up protocols make it difficult to conclude how a follow-up programme should be designed. Liver imaging and carcinoembryonic antigen assay should probably be included, while the yield of frequent colonoscopies is small. A follow-up regimen based on these principles is suggested. Future studies should focus on which tests are the most cost-effective for follow-up after colorectal cancer resection.

Multimodal treatment of peritoneal carcinomatosis and sarcomatosis

Peritoneal carcinomatosis and sarcomatosis (PCS) are short-term fatal conditions amenable only to palliative treatment. They are generally considered as a systemic disease at clinical presentation, and are resistant to standard treatments. However, there may be in the natural history a phase of loco-regional tumour spread during which the tumour may still be curable. Surgical treatment alone, or in combination with systemic chemotherapy, has yielded poor results in terms of survival and quality of life. One approach is cytoreductive surgery (CS) combined with the intraperitoneal administration of antiblastic agents. This may diminish any residual tumour following macroscopic excision and may overcome the pharmacokinetic limits of systemic chemotherapy. A further improvement in this multimodal approach may be achieved by the use of hyperthermic intraperitoneal intraoperative chemotherapy (HIIC). Results so far have been encouraging. However, series reported in the literature are relatively small and heterogeneous, and clinical and technical factors which include the selection of patients, optimal drugs dosage and temperature, evaluation of outcome and costs are still under discussion.

Surgery for colorectal liver metastases with hepatic lymph node involvement: a systematic review

BACKGROUND

Liver resection for colorectal metastases is the only known treatment associated with long-term survival; extrahepatic disease is usually considered a contraindication to such treatment. However, some surgeons do not regard spread to the hepatic lymph nodes as a contraindication provided that these nodes can be excised adequately. A systematic review of the literature was undertaken to address this issue.

METHODS

An electronic search using Medline, Cancerlit and Embase databases was performed for studies reporting liver resection for colorectal metastases from 1964 to 1999. Data were extracted from papers reporting outcome for patients with positive hepatic nodes and analysed according to predetermined criteria.

RESULTS

Fifteen studies were identified that gave survival data on 145 node-positive patients. Five patients were reported to have survived 5 years after liver resection; one was disease free, two had recurrent disease and the disease status was not described in the remaining two. Five studies containing 83 patients specified a formal lymph node dissection as part of the surgical procedure and four of the five node-positive 5-year survivors were from these studies.

CONCLUSION

There are few 5-year survivors after liver resection, with or without lymph node dissection, for colorectal hepatic metastases involving the hepatic lymph nodes.

Clinical research methodologies in diagnosis and staging of patients with peritoneal carcinomatosis

The following methodologies may be strictly applied to quantitatively evaluate patients with peritoneal carcinomatosis or sarcomatosis in regard to disease progression or regression: (1) Preoperative CT scan and the intraoperative assessment of cancer extent is analyzed region by region (AR-0-12) and an estimation of tumor volume (V0-V3) is evaluated according to the standardized scoring system previously described. At laparotomy, the volume of tumor nodules to adjacent organs, the viscosity (mucinous vs. solid) of tumor mass, and the pattern of distribution is assessed. (2) Radiologic abdominopelvic CT parameters that predict an incomplete cytoreduction are focal obstructions of bowel by CT assessment and tumor involvement of proximal ileum (AR-11). (3) The extent of prior surgical interventions (PS-1 through PS-3) must be recorded because aggressive deep dissections without perioperative chemotherapy severely jeopardize the possibility for complete cytoreduction. (4) Many tumor samples should be sent for histopathologic analysis. A proportion of mucin > 80% confirms a mucinous cancer. The malignant differentiation of cells, stroma morphology, the presence of signet ring cells, and evidence of invasion are used to grade cancers as mucinous tumor grade 0-3 (MTG-0 through MTG-3). (5) Once the cytoreductive procedure is accomplished, the surgeon estimates the residual volume of disease. (6) Objective response criteria from CT scan, tumor marker, and radiolabeled monoclonal antibody studies are necessary in a regular follow-up schedule.

Patterns of recurrent colorectal cancer and recovery surgery

In only two areas of colorectal cancer recurrence does surgery provide benefit. For a minority of patients with liver metastases that can be resected completely, cure is possible. Recent data from a prospective liver surgery protocol provide a perspective on the outcome, morbidity, and mortality of the procedure and confirm many of the suggestions in previous retrospective reviews. For patients with isolated pelvic or perineal recurrence, surgical removal of recurrent tumor provides palliation, but only if in-hospital convalescence is minimal and if recently introduced reconstructive techniques allow early rehabilitation.

Colorectal cancer. The bases for a comprehensive follow-up

The purpose of this article was to review the effectiveness of follow-up in patients with colorectal cancer submitted to curative treatment. A comprehensive follow-up involves rational initial management of the primary tumor, knowledge of prognostic factors, selection of the patient to be followed, determination of the time for follow-up, use of the most appropriate tests for early diagnosis of recurrence, and eventual curative treatment. The updated answers to all these questions are given through an extensive review of the world literature and confronted with the authors' experience of eight years of follow-up in a series of 170 colorectal cancer patients treated for cure. Although the future might be more promising, past world experience suggests only a few patients could be saved. It is concluded that there is no place for incomplete and disperse screening tests, and only comprehensive, intensive, and very well-coordinated follow-up programs should be undertaken if better results are hoped to be achieved.

[The problem of recurrence in colonic cancer]

In this study the incidence of recurrence in radical procedure for carcinoma of colon is more than 37.4%. Of 100 patients undergoing second laparotomy because of recurrence 33% could be resected curatively. The rate of recurrence was independent on sex, negatively correlated with age and positively correlated with tumor stage of former operations. Curative operations located at the ascending colon and hepatic flexure had less recurrences than others. Second operations in curative aims were twice as successful in men than in woman and equally possible in all decades. Results of recurrences of splenic flexure and transverse colon were better than other locations. Tumors of early stages relapsed later. The probability of a radical procedure in recurrence related operations was better in those cases with a long recurrence-free interval. The resectability +/- rate and tumor stage of second-look operation were depending on tumor stage in the first operation. This means further history of tumor disease is determined closely by tumor stage in the first operation.