Locoregional recurrence and survival after curative resection of adenocarcinoma of the colon

Cumulative incidence of first recurrence after curative treatment of stage I-III colorectal cancer. Competing risk analyses of temporal and anatomic patterns

BACKGROUND

Updated knowledge about the rates of recurrence and time to recurrence following curative treatment of colorectal cancer is essential to secure better patient information on prognosis, to serve as a premise in the discussion on adjuvant chemotherapy, and help to properly scale the intensity and length of follow-up.

METHODS

This is a population-based study investigating aspects on first recurrence after radical treatment of clinical stages I-III of colorectal cancer in Central-Norway during 2001-2015. To reveal any time-trends, data were stratified by the time periods 2001-2005, 2006-2010 and 2011-2015. The cumulative incidence of first recurrence was calculated, treating death of unrelated causes as a competing event. Multivariable Cox analyses were done to calculate cause specific hazard ratios (HR) for risk of recurrence.

RESULTS

At a minimum follow-up of six years, a first recurrence was detected in 1,113/5,556 patients at risk (20.0%). The recurrence rate was reduced from 23.6% in the first time period, through 20.0% in the second, and to 17.2% in the last, p < 0.001. The reduction applied to all tumor locations, to pathological disease stages II and III, to both gender, across different tumor differentiations, and to both elective and emergency surgery. In multivariable analyses time period, gender, disease stage, and tumor differentiation were significant determinants for risk of recurrence.

CONCLUSIONS

The rate of first recurrence after curative surgery for colorectal cancer was substantially reduced from 2001 to 2015. The reason for the reduction could not be attributed to a single factor only. A combined effect of several incremental improvements, such as an increased use of preoperative radiation for rectal cancers, improved adjuvant chemotherapy for colon cancer, and a reduced proportion of emergency surgery, is suggested.

Clinicopathological Characteristics of Anastomotic Recurrence After Curative Resection for Colorectal Cancer: Comparison With Nonanastomotic Local Recurrences

BACKGROUND

Anastomotic recurrence is thought to be caused by implantation of tumor cells to the anastomotic line; however, its risk factors and prognostic significance remain unclear.

OBJECTIVE

This study aimed to clarify the risk factors for anastomotic recurrence in colorectal cancer and assess the prognosis in comparison to nonanastomotic local recurrence.

DESIGN

A single-center retrospective observational study.

SETTINGS

The medical records of the study participants were retrospectively collected from the Department of Surgical Oncology at the University of Tokyo Hospital database.

PATIENTS

This study included 1584 patients with colorectal cancer who underwent surgical resection between January 2005 and December 2017. We focused on 15 patients who had an anastomotic recurrence.

MAIN OUTCOME MEASURES

The main outcome measures were the risk factors of anastomotic recurrence at the primary resection and prognosis data in comparison to that of nonanastomotic local recurrence.

RESULTS

There were 15 patients (0.95%) with anastomotic recurrence and 35 (2.21%) with nonanastomotic local recurrence. Univariate analysis revealed that lymph node metastasis and advanced T stage are the risk factors for anastomotic recurrence. The prognosis of patients with anastomotic recurrence was similar to that of those with nonanastomotic local recurrence who underwent resection.

LIMITATIONS

The small number of patients with anastomotic recurrence is a major limitation of this study. Additionally, the retrospective study design may have increased the risk of selection bias.

CONCLUSIONS

Lymph node metastasis and advanced T stage were associated with anastomotic recurrence. The prognosis of patients with anastomotic recurrence was similar to that with resected nonanastomotic local recurrence. Thus, surveillance should be carefully continued while considering the poor prognosis of patients with anastomotic recurrence. See Video Abstract at http://links.lww.com/DCR/C92 .

CARACTERSTICAS CLINICOPATOLGICAS DE LA RECURRENCIA ANASTOMTICA DESPUS DE LA RESECCIN CURATIVA DEL CNCER COLORRECTAL COMPARACIN CON LAS RECURRENCIAS LOCALES NO ANASTOMTICAS

ANTECEDENTES:Se cree que la recurrencia anastomótica es causada por la implantación de células tumorales en la línea anastomótica; sin embargo, los factores de riesgo asociados y el significado en cuanto a pronóstico siguen sin estar claros.OBJETIVO:Este estudio tuvo como objetivo aclarar los factores de riesgo para la recurrencia anastomótica en el cáncer colorrectal y evaluar el pronóstico en comparación con la recurrencia local no anastomótica.DISEÑO:Un estudio observacional retrospectivo de un solo centro.ESCENARIO:Los registros médicos de los participantes del estudio se recopilaron retrospectivamente de la base de datos del Departamento de Cirugía Oncológica del Hospital de la Universidad de Tokio.PACIENTES:Este estudio incluyó a 1584 pacientes con cáncer colorrectal que se sometieron a resección quirúrgica entre enero de 2005 y diciembre de 2017. Nos enfocamos en 15 pacientes que tuvieron recurrencia anastomótica.PRINCIPALES MEDIDAS DE RESULTADO:Las principales medidas de resultado fueron los factores de riesgo de recurrencia anastomótica en la resección primaria y los datos de pronóstico en comparación con la recurrencia local no anastomótica.RESULTADOS:Hubo 15 pacientes (0.95%) con recurrencia anastomótica y 35 (2.21%) con recurrencia local no anastomótica. El análisis univariable reveló que la metástasis en los ganglios linfáticos y el estadio T avanzado son los factores de riesgo para la recurrencia anastomótica. El pronóstico de los pacientes con recidiva anastomótica fue similar al de aquellos con recidiva local no anastomótica sometidos a resección.LIMITACIONES:El pequeño número de pacientes con recurrencia anastomótica es una limitación importante de este estudio. Además, el diseño retrospectivo del estudio puede haber aumentado el riesgo de sesgo de selección.CONCLUSIONES:La metástasis en los ganglios linfáticos y el estadio T avanzado se asociaron con recurrencia anastomótica. El pronóstico de los pacientes con recidiva anastomótica fue similar al de la recidiva local no anastomótica resecada. Por lo tanto, la vigilancia debe continuarse cuidadosamente considerando el mal pronóstico de los pacientes con recurrencia anastomótica. Consulte Video Resumen en http://links.lww.com/DCR/C92 . (Traducción-Dr. Jorge Silva Velazco ).

Late Recurrence of Colorectal Carcinoma in Patients with Malignant Polyp and Risk Factors

Malignant polyps are polypoid lesions that appear benign endoscopically but harbor invasive adenocarcinoma microscopically. Patient with diagnosis of malignant polyp can be managed by surgical resection or endoscopic surveillance. Current literature on long term recurrence is sparse. A total of 76 patients with malignant polyp and follow-up period of over one year are included. Of these, 28 patients underwent endoscopic polypectomy followed by surveillance (group 1). Forty-eight patients underwent segmental colectomy (group 2). In group 1, three patients developed local recurrent pT3 adenocarcinoma (5.9 to 9.7 years) and one patient developed liver metastasis (7.3 years). One patient presented with malignant polyp in another segment of colon (4.0 years). Two of the malignant polyps with local recurrence do not have commonly reported high-risk features, including tumor ≤ 1 mm from resection margin, presence of lymphovascular invasion and high grade tumor, they had invasion depth of >4 mm and harbored a TP53 missense mutation. In group 2, during the follow-up period (1.0-21.8 years, median 9.3 years), none of the patients developed local recurrence. In this study, surveillance group had a local late recurrence rate of 10.7% versus no local recurrence in surgical resection group (0%). Our study shows that depth of invasion of over 4 mm in malignant polyp is a risk factor for late local recurrence if managed by endoscopic surveillance. Further study is needed to explore whether certain molecular alterations, such as TP53 mutation, is a risk factor for late recurrence.

Locoregionally Recurrent Colon Cancer: How Far Have We Come? A Population-Based, Retrospective Cohort Study

BACKGROUND

The reported outcomes of locoregionally recurrent colon cancer (LRCC) are poor, but the literature about LRCC is scarce and aged. Recent population-based studies to provide current insight into LRCC are warranted. This study aimed to provide an overview of the incidence, risk factors, treatment, and overall survival (OS) of patients with LRCC after curative resection of stage I-III primary colon cancer.

METHODS

Data on disease recurrence were collected for all patients with a diagnosis of non-metastasized primary colon cancer in the Netherlands during the first 6 months of 2015. Patients who underwent surgical resection (N = 3544) were included in this study. The 3-year cumulative incidence, risk factors, treatment, and OS for patients with LRCC were determined.

RESULTS

The 3-year cumulative incidence of LRCC was 3.8%. Synchronous distant metastases (LRCC-M1) were diagnosed in 62.7% of the patients. The risk factors for LRCC were age of 70 years or older, pT4, pN1-2, and R1-2. Adjuvant chemotherapy was associated with a decreased risk of LRCC for high-risk stage II and stage III patients [hazard ratio (HR), 0.47; 95% confidence interval (CI) 0.31-0.93]. The median OS for the patients with LRCC was 13.1 months (95% CI 9.1-18.3 months). Curative-intent treatment was given to 22.4% of the LRCC patients, and the subsequent 3 years OS was 71% (95% CI 58-87%). The patients treated with palliative treatment and best supportive care showed 3-year OS rates of 15% (95% CI 7.0-31%) and 3.7% (95% CI 1.0-14%), respectively.

CONCLUSIONS

The cumulative incidence of LRCC was low, and adjuvant chemotherapy was associated with a decreased risk for LRCC among targeted patients. Curative-intent treatment was given to nearly 1 in 4 LRCC patients, and the OS for this group was high.

Surgery of resectable local recurrence following colorectal cancer: Compartmental surgery improves local control

BACKGROUND

This study aims to identify prognostic factors and define the best extent of surgery for optimizing treatment of local recurrence (LR) following colorectal cancer (CRC).

METHODS

An institutional database of consecutive patients who underwent radical resection (R0/R1) of LR following CRC was analyzed prospectively from 2010 to 2021 at one tertiary cancer center.

RESULTS

In this study, 75 patients were included with LR following CRC and analyzed. Patients were categorized as compartmental resections (CompRe) (n = 47) if all adjacent organs were systematically removed, with or without tumor involvement, or noncompartmental resections (NoCompRe) (n = 28) if only contiguously involved organs were resected. NoCompRe were mainly related to contact between major vessels or bone and the tumor, with only 8/19 (42.1%) resections. Five-year overall survival and locoregional-free survival were 37.5% and 38.8% respectively. Local control was better in the CompRe than the NocompRe group (61.4% vs. 11%; p < 0.01). CompRe (hazard ratio: 2.34 [1.16-4.68]; p = 0.017) and absence of peritoneal metastasis (3.05 [1.03-9.02]; p = 0.044) were the two factors associated with decreased abdominal recurrences in multivariate analysis.

CONCLUSION

Complete compartmental surgery is safe and improves local control. Optimal LR resection needs to remove all contiguous organs, with or without tumor involvement.

Postoperative Quality Assessment Score Can Select Patients with High Risk for Locoregional Recurrence in Colon Cancer

BACKGROUND

Monitoring surgical quality has been shown to reduce locoregional recurrence (LRR). We previously showed that the arterial stump length (ASL) after complete mesocolic excision (CME) is a reproducible quality instrument and correlates with the lymph-node (LN) yield. We hypothesized that generating an LRR prediction score by integrating the ASL would predict the risk of LRR after suboptimal surgery.

METHODS

502 patients with curative resections for stage I-III colon cancer were divided in two groups (CME vs. non-CME) and compared in terms of surgical data, ASL-derived parameters, pathological parameters, LRR and LRR-free survival. A prediction score was generated to stratify patients at high risk for LRR.

RESULTS

The ASL showed significantly higher values (50.77 mm ± 28.5 mm) with LRR vs. (45.59 mm ± 28.1 mm) without LRR (p < 0.001). Kaplan-Meier survival analysis showed a significant increase in LRR-free survival at 5.58 years when CME was performed (Group A: 81%), in contrast to non-CME surgery (Group B: 67.2%).

CONCLUSIONS

The prediction score placed 76.6% of patients with LRR in the high-risk category, with a strong predictive value. Patients with long vascular stumps and positive nodes could benefit from second surgery to complete the mesocolic excision.

The Value of Sentinel Lymph Node Mapping for the Staging of Node-Negative Colon Cancer: Propensity Score and Mediation Analyses

Objectives

Mediation analysis to assess the protective impact of sentinel lymph node (SLN) mapping on prognosis and survival of patients with colon cancer through a more precise evaluation of the lymph node (LN) status.

Background

Up to 20% of patients with node-negative colon cancer develop disease recurrence. Conventional histopathological LN examination may be limited in describing the real metastatic burden of LN.

Methods

Data of 312 patients with stage I & II colon cancer was collected prospectively. Patients were either staged using intraoperative SLN mapping with multilevel sectioning and immunohistochemical staining of the SLN or conventional techniques. The value of the SLN mapping for the detection of truly node-negative patients was assessed using Cox regression and mediation analysis.

Results

SLN mapping was performed in 143 patients. Disease recurrence was observed in 13 (9.1%) patients staged with SLN mapping and in 27 (16%) staged conventionally. Five-year overall survival (OS) rate was 82.7% (95% confidence interval [CI], 76.5-89.4%) with SLN mapping compared with 65.8% (95% CI, 58.8-73.7%). Five-year cancer-specific survival (CSS) was 95.1% (95% CI, 91.3-99.0%) with SLN mapping compared with 92.5% (95% CI, 88.0-97.2%). Node-negative staging with SLN mapping was associated with significantly better OS (hazard ratio [HR], 0.64; 95% CI, 0.56-0.72; P < 0.001) and CSS (HR, 0.49; 95% CI, 0.39-0.61; P < 0.001) in multivariate analysis. Mediation analysis confirmed a direct protective effect of SLN mapping on OS (HR, 0.78; 95% CI, 0.52-0.96; P < 0.01) and disease-free survival (DFS) (HR, 0.75; 95% CI, 0.48-0.89; P < 0.01).

Conclusions

Staging performed by SLN mapping with multilevel sectioning provides more accurate results than conventional staging. The observed clinically relevant and statistically significant benefit in OS and DFS is explained by a more accurate detection of positive LN by SLN mapping.

Core Circadian Clock Proteins as Biomarkers of Progression in Colorectal Cancer

Colorectal cancer (CRC) is one of the most common tumours in developed countries. Although its incidence and mortality rates have decreased, its prognosis has not changed, and a high percentage of patients with CRC develop relapse (metachronous metastasis, MM, or local recurrence, LR) during their disease. The identification of these patients is very important for their correct management, but the lack of prognostic markers makes it difficult. Given the connection between circadian disruption and cancer development and progression, we aimed to analyse the prognostic significance of core circadian proteins in CRC. We measured the expression of PER1-3, CRY1-2, BMAL1 and NR1D2 in a cohort of CRC patients by immunohistochemistry (IHC) and analysed their prognostic potential in this disease. A low expression of PER2 and BMAL1 was significantly associated with metastasis at the moment of disease diagnosis, whereas a high expression of CRY1 appeared as an independent prognostic factor of MM development. A high expression of NR1D2 appeared as an independent prognostic factor of LR development after disease diagnosis. Moreover, patients with a low expression of BMAL1 and a high expression of CRY1 showed lower OS and DFS at five years. Although these markers need to be validated in larger and different ethnic cohorts, the simplicity of IHC makes these proteins candidates for personalizing CRC treatment.

Long-term outcomes of resection for locoregional recurrence of colon cancer: A retrospective descriptive cohort study

INTRODUCTION

Resection for isolated distant recurrence of colon cancer is well accepted. Resection for locoregionally recurrent colon cancer (LRCC) is not well studied. We evaluated the long-term outcomes of curative-intent resection for LRCC.

METHODS

All patients undergoing curative-intent resection for LRCC at three specialized cancer centers affiliated with the University of Toronto were identified (1993-2017). Follow-up included serial clinical assessment, colonoscopy, CEA, and cross-sectional imaging. Overall survival (OS), cancer-specific survival (CSS) and time to re-recurrence were estimated using Kaplan-Meier method and cumulative incidence function. The association between resection margins and outcome was assessed with Cox models.

RESULTS

117 patients were included in the study cohort. Median follow-up was 53 months (IQR: 34-101). OS was 75% (95% CI: 68-84) at 5 years, and 69% (95% CI: 59-79) at 10 years. CSS was 78% (95% CI: 70-86) at 5 years and 72% (95% CI: 63-83) at 10 years. The rate of re-recurrence was 22% (95% CI: 14-31) at 5 years, and 27% (95% CI: 16-39) at 10 years. Negative resection margin (R0) was associated with improved OS (HR 3.33, 95% CI: 1.85-6.00, p < 0.01). There were no postoperative deaths; complications with Clavien-Dindo grade > II occurred in 12% of patients. Perioperative chemotherapy was used in 63% of patients and radiotherapy in 37%.

CONCLUSION

In selected patients with LRCC, excellent OS, CSS and low re-recurrence rates were observed, and R0 resection predicted better outcomes. These findings support consideration of resection for LRCC in fit patients after review at a multidisciplinary cancer conference.

The effect of different inferior mesenteric artery ligation levels and different lymph node dissection areas on the short- and long-term outcomes of rectal cancer

Background

Surgery is the most effective treatment for rectal cancer patients, but its key steps, including selection of the level of inferior mesenteric artery ligation and removal of 253 lymph nodes, are still inconclusive. This study aimed to analyze the effects of different surgical methods, including levels of ligation (low vs. high) and lymph node dissection areas (D2 vs. D3) on the short-term and long-term outcomes.

Methods

Between March 2014 and August 2018, 253 rectal cancer patients were retrospectively analyzed; 113 patients underwent low ligation D2 lymph node dissection (LLD2), 75 patients underwent low ligation D3 lymph node dissection (LLD3), and 65 patients underwent high ligation (HL). We compared the short-term and long-term outcomes among the different groups.

Results

There were no significant differences among the groups in terms of the intraoperative variables, including operative time, blood transfusion, and conversion from laparoscopic to open surgery. The median blood loss was significantly lower in LLD3 (50 mL) than in LLD2 (100 mL) and HL (100 mL), but it was not significantly different between LLD2 and HL. There were no significant differences among the LLD2, LLD3, and HL groups in the incidence of postoperative complications (9.7% vs. 12.0% vs. 10.8%, respectively) and hospital stay (14 vs. 15 vs. 14, respectively). The anastomotic leakage Clavien-Dindo grade was significantly lower with LLD2 and LLD3 than with HL, but it was the same between LLD2 and LLD3. The total number of lymph nodes harvested in the LLD3 group (n=14) was higher than that in the LLD2 group (n=12), but it was not significantly different than that in the HL group (n=13). There were no significant differences among the groups in terms of 3-year overall survival rate and disease-free survival rate.

Conclusions

Low ligation was similar to HL in terms of major intraoperative and postoperative parameters, but it can reduce the severity of anastomotic leakage to a certain extent. D3 lymph node dissection can increase the total number of lymph nodes harvested, but it did not improve long-term prognosis.

Qualitative and Quantitative Analysis of Posttreatment Strategy After Endoscopic Resection for Patients with T1 Colorectal Cancer at High Risk of Lymph Node Metastasis

BACKGROUND

Although endoscopic resection is increasingly performed to treat submucosal invasive colorectal cancer (T1CRC), approximately 10% are at risk of lymph node metastasis. The Japanese Society for Cancer of the Colon and Rectum guideline indicates that the following risk factors should be considered when deciding whether to perform additional surgical resection with lymph node dissection: depth of T1 invasion, lymphovascular invasion, poor histological grade, and budding grade 2/3. However, there is little information about the prognosis of T1CRC patients, or factors to consider when deciding subsequent treatment of high-risk T1CRC.

METHODS

This retrospective mixed method study was conducted using electronic medical records at Kyoto University Hospital between February 2005 and February 2015. Participants were T1CRC patients at risk of lymph node metastasis with at least one of the above four risk factors. They were assigned either careful follow-up (FU) or additional surgery (AS) through shared decision-making. To identify factors affecting decision-making in the FU group, we performed qualitative content analysis of electronic medical records. The prognosis of the groups was compared using the Kaplan-Meier method and the log-rank test.

RESULTS

Of 161 T1CRC patients, 18 were included in the FU group and 19 in the AS group. The median follow-up time was 39.5 (range 23-126) months for the FU group and 62 (range 22-141) months for the AS group. Factors considered in selecting FU were advanced age, comorbidities, the sole presence of the "depth" risk factor, and lower rectal cancer. For AS, the risk factors cited in the guideline were considered. There was one recurrent case in each group during the research period. There were no significant differences in overall survival, cause-specific survival, or recurrence-free survival between the groups.

CONCLUSIONS

Age, comorbidities, and lower-rectal cancer location were considered in deciding posttreatment strategy among high-risk T1CRC patients, alongside with positive vertical margin, depth, lymphovascular invasion, poor histologic grade, and budding. During the research period, there was no prognostic difference between the FU and AS groups.

Prospective analysis of tumor spread to the small bowel mesentery in cases of right-sided colon cancer

PURPOSE

Guidelines advocate minimal ileal resection when right hemicolectomy is performed for right-sided colon cancer. The practice, thought to prevent malabsorption syndrome, does not appear to foster local recurrence. Little evidence based on rigorous study exists, however. To understand the pattern of lymphatic spread of right-sided colon cancer toward the small bowel and thus determine the appropriate margin size, we prospectively investigated anatomical distribution of lymph nodes (LNs) in the small bowel mesentery and of metastasis to these nodes in patients with right-sided colon cancer treated by such surgery.

METHODS

In each case, the mesenteric specimen, which had been dissected along the ileocolic vessels and included intermediate LNs, was divided into 2 areas: that 0-3 cm from the vessel pedicle (area 1) and that 3-5 cm from the pedicle (area 2). The peri-intestinal mesentery was cut into 9 segments.

RESULTS

Ninety-one patients were included in the study. Overall, 3366 LNs were dissected. Four hundred fifty-three of these LNs were located in area 1 (90 cases), and 15 (3.3%) were metastatic. Only 63 LNs were located in area 2 (34 cases; average of 0.69 per patient); none was metastatic. Overall, 269 LNs were found in the small bowel mesentery (in 56 of the 91 patients). Only 4 were positive (3 cases), and all were within 5 cm of the ileocecal valve.

CONCLUSION

Our data indicate that a surgical margin 3 cm from the ileocecal pedicle and a short (5 cm) ileal margin are oncologically reasonable for effective right hemicolectomy.

Surgical management of recurrent colon cancer

There have been significant developments in the management of advanced and recurrent colorectal cancer in recent decades. 70% of primary colorectal tumours arise in the colon and for patients with stage I-III disease, the standard of care is surgical resection followed by adjuvant therapy where appropriate. Locoregional recurrence (LR) occurs in 4-11.5% of patients following treatment of primary colon cancer with curative intent, and can be categorised as peri-anastomotic, mesenteric/paracolic (nodal), retroperitoneal and peritoneal. Of these, peritoneal recurrence is usually recognised as the most challenging type of recurrence to manage. Patients with isolated peri-anastomotic or limited nodal recurrence in the mesentery or retroperitoneum may be curable by radical salvage surgery, which often requires en bloc multi-visceral resection, while patients with low volume peritoneal metastases may be candidates for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Ensuring complete resection along embryonic mesocolic planes or en bloc resection of contiguously involved structures are best strategies to reduce the likelihood of local recurrence through a R1 resection margin. The role of complete mesocolic excision (CME) with high vascular ligation has been demonstrated to increase nodal yield and improve overall survival although this is more contentious. In patients with T4a disease and serosal surface involvement, peritoneal recurrence represents the greatest threat. Efforts for early diagnosis of peritoneal recurrence in these patients or prophylactic treatment, while intuitive have not demonstrated the survival benefit that would be expected. Other than locoregional recurrence (LR), systemic recurrence may occur in up to 50% of patients who have undergone curative resection for colorectal cancer. In keeping with portal venous outflow, the most common site of systemic recurrence is the liver. Although previously thought to be a fatal condition, liver resection is now the standard of care where liver metastases can be completely resected with clear margins plus leaving an adequate liver remnant with intact vascular inflow, outflow and biliary drainage. This can usually be achieved in 26-45% of patients presenting with liver metastases. Liver surgeons at the forefront of liver resection have also developed techniques to induce liver hypertrophy so as to improve likelihood of resectability. Even where patients have non-resectable disease, ablative techniques have become increasingly common. Naturally, none of these would be possible without the advent of improved chemotherapeutic and biological options in the field of medical oncology. Pulmonary metastasectomy with curative intent may be possible in a small number (10%) of patients with lung metastases, which is associated with an overall survival of up to 40%. Unlike liver metastases, proportionally less patients with pulmonary metastases will be resectable. For these patients, several ablative options are available. For all patients with recurrent colon cancer, patient selection for radical salvage surgery and decisions surrounding treatment strategy (including use of systemic therapy or ablative procedures) should take place in a multidisciplinary team setting.

Curative-intent surgery for isolated locoregional recurrence of colon cancer: Review of the literature and institutional experience

BACKGROUND

Locoregional recurrence of colon cancer (LRCC) following curative resection is an underreported clinical entity, especially regarding isolated LRCC which is amenable for surgery. The purpose of this study was to review the literature on incidence of LRCC and surgical treatment with corresponding outcome, and to describe an institutional experience with curative-intent surgery, whether or not as part of a multimodality approach.

METHODS

The PubMed and Medline literature databases 1978-2017 were searched and retrieved articles were assessed for eligibility. Based on a prospectively maintained database since 2010 at a tertiary referral center, original patient files were retrospectively reviewed.

RESULTS

Systematic literature review resulted in 11 studies reporting on incidence of LRCC, which ranged from 3.1% to 19.0% before 2010, and from 4.4% to 6.7% in three most recent studies. Twelve identified studies reported on outcome of surgically treated LRCC, with a median survival of 30 and 33 months in the two largest studies. The institutional database entailed 17 patients who underwent resection of isolated LRCC between 2010 and 2018. Median time to recurrence was 19 months. After a median follow-up after resection of LRCC of 20 months, 7 patients had died, 9 patients were alive without evidence of disease and 1 patient with evidence of disease; Median DFS was 36 months and 3-year OS was 65%.

CONCLUSION

Locoregional recurrence of colon cancer occurs in about 5% in most recent series, of whom selected patients are eligible for surgical treatment, with a fair chance of long-term disease control.

Intra-abdominal recurrence from colorectal carcinoma: Differences and similarities between local and peritoneal recurrence

BACKGROUND

Peritoneal recurrences from colo-rectal cancer can be isolated (PR) or associated with local recurrences (LR). The purpose of this study was to analyze patterns and outcomes of LR and PR.

METHODS

Analyze from a prospective database of 108 patients treated with CCS plus HIPEC at two cancer centers between 2008 and 2015.

RESULTS

The population was divided into an LPR group (presence of LR with or without PR, n = 56) and a PR group (isolated PR, n = 52). The patients characteristics (age, sex, Charlson score, PCI) or perioperative treatments were comparable between the groups. The median number of resected organs for tumor involvement (respectively, 2 vs 1; p < 0.001), the percentage of patients with metastatic lymph nodes (LN+) from the resected specimen (respectively, 25% vs 7%; p = 0.016) and the mortality rate (respectively, 9% vs 0%; p = 0.023) were significantly higher in the LPR group. After a median follow-up of 32 (1-108) months, median overall survival was comparable between the two groups (respectively, 46 vs 42 months; p = 0.262).

CONCLUSIONS

LR is associated with a higher incidence of organ invasion, LN involvement (25%) and postoperative mortality. Optimal surgical resection of LR with systematic lymphadenectomy of invaded organs seems mandatory.

Prognostic Impact of pT Stage and Peritoneal Invasion in Locally Advanced Colon Cancer

BACKGROUND

TNM stage has been identified as an independent variable for local recurrence and survival after colon cancer resection. It is still unclear whether peritoneal invasion (pT4a) is a risk factor for adverse oncologic outcome or whether these patients have better results compared with contiguous organs infiltration (pT4b), independent from nodal status (pN).

OBJECTIVE

The purpose of this study was to analyze whether peritoneal invasion is an independent risk factor for worse oncologic outcome after curative colon cancer resection.

DESIGN

This was a retrospective analysis with multivariate regression of a prospective database, according to Strengthening the Reporting of Observational Studies in Epidemiology Statement.

SETTINGS

The study was conducted in a specialized colorectal unit of a tertiary hospital.

PATIENTS

A consecutive series of pT3-pT4a-pT4b patients with colon cancer who underwent curative surgery (1993-2010) were included, and patients with metastasis were excluded.

MAIN OUTCOME MEASURES

A multivariate Cox regression analysis was performed to assess independent risk factors for 5-year local recurrence, peritoneal carcinomatosis-like recurrence, disease-free survival, and cancer-specific survival.

RESULTS

A total of 1010 patients were analyzed (79.3% pT3, 9.9% pT4a, and 10.8% pT4b). At diagnosis, 22.0% had obstructive symptoms, and 10.5% had bowel perforation. A total of 72.2% of the surgeries were elective, and in 15.6% en bloc resection of contiguous organs was performed. Median follow-up was 62 months (38-100 mo). For the whole group, 5-year actuarial rates were 8.8% for local recurrence, 2.5% for peritoneal carcinomatosis, 75.5% for disease-free survival, and 81.8% for cancer-specific survival. At multivariate analysis, pT4a stage was an independent risk factor for local recurrence (p = 0.002; HR = 3.1), peritoneal carcinomatosis (p = 0.02; HR = 4.9), worse disease-free survival (p = 0.002; HR = 1.9), and cancer-specific survival (p = 0.001; HR = 2.2). When considering only the 566 patients with ≥12 nodes identified, T stage was still associated with higher local recurrence (p = 0.04) and carcinomatosis rate (p = 0.04), as well as worse disease-free (p = 0.009) and cancer-specific survival (p = 0.014).

LIMITATIONS

This was a retrospective, single-center study.

CONCLUSIONS

pT4a stage is an independent risk factor for worse oncologic outcome after curative colon cancer resection compared with pT3 and pT4b stages. The current pT4a-pT4b classification should be reconsidered. Of note, even in pT4a patients, 5-year carcinomatosis rate does not exceed 6%. See Video Abstract at http://links.lww.com/DCR/A926.

[Local recurrences of colon cancer (in Russian only)]

AIM

To evaluate the outcomes in patients with local recurrences (LR) of colon cancer.

MATERIAL AND METHODS

Prospective study included 52 patients with local recurrences of colon cancer MR and no distant metastases or disseminated carcinomatosis. Patients have been treated at Ryzhikh State Research Center for Coloproctology for the period 2009-2017. Median of local recurrence was 17.6 months. By the moment of diagnosis, CEA was increased in 24 (46.2%), CA 19-9 - in 4 (7.7%) patients. Forty-eight (92%) patients underwent surgery for local recurrences of colon cancer. In 26 (54%) cases, low ligation of supplying vessel was made during primary tumor excision that was confirmed by significant fragment of intact mesentery of the colon.

RESULTS

Radical surgery for LR was possible in 34 (70.8%) patients, resection of more than one organ was required in 60% of cases. R1-resection was obtained in 12 (25.0%) cases, palliative resections - in 2 (4.2%) patients. Various complications occurred in 34 (70.8%) patients. Additional intraperitoneal chemotherapy was need in 12 (23.1%) cases. Lethal outcomes were absent. Forty-six out of 48 (95.8%) patients were followed-up. Mean follow-up was 19.5 (8.6-34.7) months. Twelve (26.1%) patients were free from recurrent cancer. Only distant metastases developed in 16 (34.8%) patients. Redo LR occurred in 18 (39.1%) patients including 12 of them with distant metastases. Overall 5-year survival was 38%, disease-free survival - 17.5%, median overall survival - 42.8 months, median disease-free survival - 15.2 months. Intraperitoneal chemotherapy did not significantly affect overall survival. Multivariate analysis confirmed high level of CEA and CA 19-9, positive resection margin as negative predictors. Moreover, impaired survival (p=0.03) was noted in case of LR after non-radical surgery for primary tumor with high ligation of the vessel.

CONCLUSION

R0-resection is essential to improve survival and reduce incidence of recurrences. Intraoperative intra-abdominal chemotherapy does not affect the outcomes in patients with LR of colon cancer. Adherence to surgical principles for cancer can reduce the incidence of LR.

Association between KRAS G13D mutations and anastomotic recurrence in colorectal cancer: Two case reports

RATIONALE

The prevalence of anastomotic recurrence (AR) in colorectal cancer (CRC) after resection of the primary tumor (PT) is 5% to 14%. However, no association has been observed between specific somatic genetic alterations and AR. Such associations may shed light on the mechanism of AR.

PATIENT CONCERNS

We experienced 2 patients with AR of CRC. The first patient was a 42-year-old woman who underwent resection of an AR of rectal cancer 2 times within 19 months after resection of the PT. The second patient was a 77-year-old woman who underwent resection of an AR of ascending colon cancer twice within 38 months after resection of the PT.

DIAGNOSIS

Both cases were diagnosed as repetitive AR.

INTERVENTIONS

Loss of heterozygosity analysis, microsatellite instability (MSI) study of 9 microsatellite loci, and mutational analysis of KRAS, BRAF, APC, TP53, and SMAD4 were performed.

OUTCOMES

All the lesions, except 1, harbored mutations in APC, KRAS, and TP53, without MSI, after neoadjuvant chemoradiotherapy. The APC, KRAS, and TP53 mutations were pathogenic or likely pathogenic in the PTs and ARs. Both women harbored the same KRAS G13D mutation, which accounts for 8% of all KRAS mutations in sporadic CRC s. The probability of the incidental occurrence of KRAS G13D mutations in both cases is 0.64%, provided that the mutations were independent of AR.

LESSONS

Our findings may shed light on the mechanism of AR in CRC, namely, that the PT harbored the same mutations as the AR and the lesions in both cases harbored the KRAS G13D mutation.

Minimally Invasive Colon Cancer Surgery

Colon cancer is the second leading cause of cancer death in the United States. Advances in surgical resection techniques, including minimally invasive colectomy, are becoming a standard of care. The oncologic principles of colectomy have included adequate lymphadenectomy, proximal ligation of primary vessels, and resection with adequate longitudinal margins. More recently, complete mesocolic excision has been advocated. Open and minimally invasive approaches must accomplish the same outcomes. This article focuses on the surgical principles of colon cancer, perioperative considerations, and technical aspects of minimally invasive colectomy. We review the current literature regarding oncologic and short-term outcomes of minimally invasive surgery.

High Tie or not in Resection for Cancer in the Sigmoid Colon?

BACKGROUND AND AIMS

The optimal extent of mesenteric resection in colon cancer surgery remains elusive. The aim was to assess the impact on perioperative morbidity and oncological outcome depending on the height of central vessel ligation in sigmoid resection for adenocarcinomas.

MATERIAL AND METHODS

All cases of stage I-III sigmoid cancers, operated on with locally radical resections (2007-2009), were identified in the Swedish Colorectal Cancer Registry and categorized according to the position of the vascular ligature, that is, ligation of the inferior mesenteric artery, ligation of the superior rectal artery, or ligation of the sigmoid branches.

RESULTS

In total, 999 cases were identified and possible to categorize. Although higher ligation level yielded a higher number of lymph nodes, 3- or 5-year overall survival, 5-year disease-free survival, or recurrence rate did not differ between the groups (p = 0.79, p = 0.41, p = 0.67, p = 0.51). No differences in survival were detected after multivariate analysis adjusted for age, sex, T-stage, N-stage, American Society of Anesthesiologists classification, and adjuvant therapy.

CONCLUSION

This large population-based study showed increased lymph node yield but no survival benefit or any decreased recurrence rate by high tie in resection of sigmoid cancer.

[Influence of primary lymph node status of colorectal cancer on the development of pulmonary metastases and thoracic lymph node metastases]

BACKGROUND

The lungs are the second most common organ site for metastases in patients with colorectal cancer (CRC). Lymph node metastasis of CRC represents a prognostic factor for survival.

OBJECTIVE

The present study investigated the influence of CRC lymph node metastasis on lung metastasis, in particular thoracic lymph node metastasis.

MATERIAL AND METHODS

A retrospective analysis of 88 patients (n = 56 male) with curative resection of lung metastases of CRC was performed. Primary endpoint: influence of lymph node status of CRC on lung metastases. Secondary endpoints: disease-free survival and overall survival. Statistical evaluation was carried out with SPSS.

RESULTS

In 48 patients a positive lymph node status of CRC and in 9 patients an N+ status of lung metastases were determined. The lymph node status of the CRC significantly affected the incidence of synchronous metastases (p = 0.03), disease-free interval until formation of metachronous lung metastases (p = 0.012) and the overall survival of patients with CRC (p = 0.048). The 5‑year survival rate for CRC patients with lung metastases was 48.7% after pulmonary metastasectomy. Thoracic lymph node involvement also significantly affected survival (p = 0.001).

CONCLUSION

Screening for pulmonary metastases should be included in the staging and follow-up of all patients with CRC, especially in patients with a positive lymph node status of the CRC.

D2 VS D3 LYMPH NODE DISSECTION FOR RIGHT COLON CANCER (review)

Collapse

High tie versus low tie of the inferior mesenteric artery in colorectal cancer: A meta-analysis

BACKGROUND

Colorectal cancer surgery includes "high tie" and "low tie"of the inferior mesenteric artery(IMA). However, different ligation level is closely related to the blood supply of anastomosis, which may increase the leakage rate, and it is unclear which technique confers a lower anastomotic leakage rate(AL) and survival advantage.

OBJECTIVE

To compare the effectiveness and impact of inferior mesenteric artery (IMA) high ligation versus IMA low ligation on anastomotic leakage, lymph nodes yield rates and 5-year survival.

METHODS

A list of these studies, published in English from 1990 to 2017, was obtained independently by two reviewers from databases such as PubMed, Medline, ScienceDirect and Web of Science. Anastomotic leakage rate, the yield of lymph nodes and 5-year survival were compared using Review Manager 5.3.

RESULTS

There was no significant difference in anastomotic leakage, number of lymph nodes retrieved and 5-year survival rate for both techniques.

CONCLUSIONS

Neither the high tie nor the low tie strategy has an evidence in terms of anastomotic leakage rate, harvested lymph nodes, and the 5-year survival rate. Further RCT is needed.

Emergency resection surgery for colorectal cancer: Patterns of recurrent disease and survival

AIM

To evaluate prognostic pathological factors associated with early metachronous disease and adverse long-term survival in these patients.

METHODS

Clinical and histological features were analysed retrospectively over an eight-year period for prognostic impact on recurrent disease and overall survival in patients undergoing curative resection of a primary colorectal cancer.

RESULTS

A total of 266 patients underwent curative surgery during the study period. The median age of the study cohort was 68 year (range 26 to 91) with a follow-up of 7.9 years (range 4.6 to 12.6). Resection was undertaken electively in 225 (84.6%) patients and emergency resection in 35 (13.2%). Data on timing of surgery was missing in 6 patients. Recurrence was noted in 67 (25.2%) during the study period and was predominantly early within 3 years (82.1%) and involved hepatic metastasis in 73.1%. Emergency resection (OR = 3.60, P = 0.001), T4 stage (OR = 4.33, P < 0.001) and lymphovascular invasion (LVI) (OR = 2.37, P = 0.032) were associated with higher risk of recurrent disease. Emergency resection, T4 disease and a high lymph node ratio (LNR) were strong independent predictors of adverse long-term survival.

CONCLUSION

Emergency surgery is associated with adverse disease free and long-term survival. T4 disease, LVI and LNR provide strong independent predictive value of long-term outcome and can inform surveillance strategies to improve outcomes.

Intraluminal ileal tumour after right hemicolectomy for cancer: An implantation recurrence or a new cancer? A case report

Introduction

Extra-anastomotic intraluminal recurrence of the colon cancer after curative surgery was rarely reported but intraluminal ileal relapse has not been described to date.We report a case of intraluminal ileal tumor arising after curative right hemicolectomy that could be ascribed to an implantation of exfoliated cancer cells.

Case report

A 71-years old man was admitted with no metastatic stenotic adenocarcinoma of the hepatic flexure and submitted, without preoperative bowel preparation, to right hemicolectomy using a "no-touch" technique. Histology showed moderately differentiated adenocarcinoma without lymph nodes involvement (pT3N0). No adjuvant therapy was prescribed. First colonoscopy three months after surgery was negative but a second endoscopic examination nine months later revealed an ileal neoplasia, presenting like an ulcer 10 cm proximally to ileocolic anastomosis. A new ileo-colic resection including past anastomosis was performed with curative intent. Pathological examination showed moderately differentiated adenocarcinoma extended to peri-visceral fat tissue with 10 tumor-free lymph nodes. (pT3N0). Six courses of Capecitabine adjuvant chemotherapy was prescribed and 32 months after second surgery, the patient is alive without disease.

Discussion

In the present case, the relatively short time from the primary surgery and the fact that recurrence occurred outside the anastomosis suggest that implantation of exfoliated malignant cells seems to be the main pathogenetic mechanism. We suppose that the high grade of primary cancer and the occlusive condition could have promoted the cancer cells reflux through the ileocecal orifice and in the transverse colon.

Conclusion

This case seems to confirm the intraluminal implanting capacity of exfoliated carcinoma cells.

Long-term outcomes after treatment for T1 colorectal carcinoma: a multicenter retrospective cohort study of Hiroshima GI Endoscopy Research Group

BACKGROUND

We aimed to clarify the long-term outcomes of patients with T1 colorectal carcinoma (CRC) after endoscopic resection (ER) and surgical resection.

METHODS

We examined T1 CRC patients treated during 1992-2008 and who had ≥5 years of follow-up. Patients who did not meet the curative criteria after ER according to the Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines were defined as "non-endoscopically curable" and classified into three groups: ER alone (Group A: 121 patients), additional surgery after ER (Group B: 238 patients), and surgical resection alone (Group C: 342 patients). Long-term outcomes and predictors of recurrence were analyzed.

RESULTS

Of the 882 patients with T1 CRC, 701 were non-endoscopically curable. Among these patients, recurrence and 5-year overall survival (OS) rates were 0.6 and 91.1%, respectively. In Groups A, B, and C, recurrence rates were 5.0, 5.5, and 3.8%, OS rates were 79.3, 92.4, and 91.5% (p < 0.01), and 5-year disease-free survival (DFS) rates were 98.1, 97.9, and 98.5%, respectively. Thirty-two patients experienced local recurrence or distant/lymph node metastasis (Group A: 6; Group B: 13; Group C: 13) and 14 patients died of primary CRC (Group A: 3; Group B: 7; Group C: 4). Age ≥65 years, protruded gross type, positive lymphatic invasion, and high budding grade were significant predictors of recurrence in non-endoscopically curable patients.

CONCLUSIONS

Our findings supported the JSCCR criteria for endoscopically curable T1 CRC. ER for T1 CRC did not worsen the clinical outcomes of patients who required additional surgical resection.

Optimum level of inferior mesenteric artery ligation for the left-sided colorectal cancer. Systematic review for high and low ligation continuum

OBJECTIVES

To compares the effectiveness and impact of high inferior mesenteric artery (IMA) versus low IMA ligation on 5-year survival, lymph node yield rates, and peri-operative morbidity and mortality. 

METHODS

The databases of Educational Resources Information Centre (ERIC), the Web of Science, EBSCO and MEDLINE were searched using MeSH terms 'colorectal cancer', 'inferior mesenteric artery', 'high ligation', 'low ligation', 'mesenteric lymph nodes', 'prognosis', and 'survival'. Only clinical studies were selected and review articles and meta-analysis were excluded. In cases of duplicate cohorts, only the latest article was included. Irrelevant articles and the articles on both right and left sided CRC were excluded. The finally selected studies were analysed for the defined end-point outcomes. 

RESULTS

The published data has shown that high IMA ligation improves the yield of harvested lymph node that allows accurate tumor staging and a more reliable estimation of prognosis. High ligation was not found to be positively correlated with increased anastomotic leakage or impaired genito-urinary function. However, high ligation demands advanced surgical expertise and longer operating time. There was no significant difference in 5-year survival rates for both techniques. Some studies have reported fatal complications of high ligation such as proximal bowel necrosis.  

CONCLUSION

Although there is no consensus, this research signals the routine use of high ligation for left-sided CRC. However, the published fatal complications following high ligation and no significant difference in 5-year survival rates demand more studies to establishing a unified protocol.

Local recurrences at the anastomotic area are clonally related to the primary tumor in sporadic colorectal carcinoma

PURPOSE

Anastomotic recurrences (AR) occur in 2-10% of colorectal carcinoma cases after resection of primary tumor (PT). Currently, there are no molecular data investigating their genetic profile and multiple theories exist about their pathogenesis. The aim of our study was to compare the genomic profile of AR to that of the patients' corresponding matched PT and, when available, to a distant metastasis (DM).

EXPERIMENTAL DESIGN

Thirty-six tumors from 14 patients were genotyped using a capture-based, next-generation assay to define the mutational status of 341 cancer-associated genes. All patients had R0 resection of their PT and AR occurred 1.1-7.0 years following PT resection. A DM or a second AR was analyzed in 8 patients. All tumors were microsatellite stable except in one patient with Lynch syndrome.

RESULTS

A total of 254 somatic mutations were detected including 138 mutations in the microsatellite stable (MSS) cases. The most commonly mutated genes were APC, KRAS, TP53, PIK3CA, ATM and PIK3R1. In all patients with MSS tumors the AR and PT shared between 50-100% of mutations, including mutations in key driver genes, consistent with these tumors being clonally related. Genetic events private to DM were not detected in AR and phylogenetic analysis showed that ARs were more closely related to PT than DM. In the Lynch syndrome patient the PT and AR showed distinct somatic mutations consistent with independent primaries.

CONCLUSIONS

ARs are clonally related to PT in sporadic colorectal carcinomas and do not appear to represent seeding of the anastomotic site by distant metastases.

Comparative evaluation of oncologic outcomes in colon cancer

PURPOSE

In this paper we report clinical variables on colon cancer series. Oncological outcomes were compared to low-income and high-income countries.

METHODS

We analysed a prospective database of 51 colon cancer patients submitted to primary tumor resection between 2010 and 2011, showing clinical variables and oncologic outcomes.

RESULTS

R0 resection obtained in 80.4%, 21.6% of patients was TNM stage IV, and only 13.7% showed TNM stage I. Disease-free survival was 32 months, overall survival was 46 months, and the tumoral recurrence rate was 9.8%. Univariate analysis showed association of serum CEA levels ≥ 5 ng/dl (p= 0.004), presence of metastasis at diagnosis (p= 0.012), compromised surgical margins (p < 0.001) and poorer tumor differentiation (p= 0.041) to death. Multivariate analysis identified compromised surgical margins as an independent risk factor for death due to colon cancer (P=0.003; odds ratio=0.36; 95% confidence interval=0.004-0.33). Nowadays, 62.7% of patients are alive.

CONCLUSION

Recurrence rate, disease-free survival and overall survival was similar to those observed in more developed countries. Serum CEA levels ≥ 5 ng/dl, the presence of metastasis at diagnosis, compromised surgical margins and poorer tumor differentiation were associated with death. A compromised surgical margin was the only independent risk factor for death.

Multicenter analysis of impact of anastomotic leakage on long-term oncologic outcomes after curative resection of colon cancer

BACKGROUND

In rectal cancer, anastomotic leakage was reported to have a negative impact on both short- and long-term outcomes. However, there is limited data on the impact of anastomotic leakage on oncologic outcomes in patients with colon cancer. We aimed to evaluate the impact of anastomotic leakage on disease recurrence and long-term survival after curative resection of colon cancer.

METHODS

This multicenter, retrospective cohort study of 4,919 consecutive patients utilized data from the Japanese Society for Cancer of the Colon and Rectum. Multivariable Cox regression analysis was used to adjust for confounding.

RESULTS

The incidence of anastomotic leakage was 2.5% and 30-day mortality was 0.21%. The 5-year overall survival rate was 80.8% in the anastomotic leakage group, compared with 90.3% in the no leak group (P = .001). In the multivariable analysis, anastomotic leakage was significantly associated with reduced overall survival rate (hazard ratio = 1.84; 95% confidence interval, 1.06-2.96). Overall disease recurrence rate was 14.1%: 21.2% in the anastomotic leakage group and 13.9% in the no leak group. There was a significant association between anastomotic leakage and local recurrence (hazard ratio = 4.63; 95% confidence interval, 1.60-10.6). In contrast, anastomotic leakage was not significantly associated with total distant recurrence. However, anastomotic leakage did show a tendency toward increasing peritoneal recurrence, although it did not reach statistical significance (hazard ratio = 2.59; 95% confidence interval, 0.79-6.29).

CONCLUSION

In our study population, anastomotic leakage was associated with reduced overall survival and with increased rate of local recurrence after curative resection for colon cancer.

Prospective multicenter registration study of colorectal cancer: significant variations in radicality and oncosurgical quality-Swiss Group for Clinical Cancer Research Protocol SAKK 40/00

PURPOSE

This study aimed to investigate in a multicenter cohort study the radicality of colorectal cancer resections, to assess the oncosurgical quality of colorectal specimens, and to compare the performance between centers.

METHODS

One German and nine Swiss hospitals agreed to prospectively register all patients with primary colorectal cancer resected between September 2001 and June 2005. The median number of eligible patients with one primary tumor included per center was 95 (range 12-204).

RESULTS

The following variations of median values or percentages between centers were found: length of bowel specimen 20-39 cm (25.8 cm), maximum height of mesocolon 6.5-12.5 cm (9.0 cm), number of examined lymph nodes 9-24 (16), distance to nearer bowel resection margin in colon cancer 4.8-12 cm (7 cm), and in rectal cancer 2-3 cm (2.5 cm), central ligation of major artery 40-97 % (71 %), blood loss 200-500 ml (300 ml), need for perioperative blood transfusion 5-40 % (19 %), tumor opened during mobilization 0-11 % (5 %), T4-tumors not en-bloc resected 0-33 % (4 %), inadvertent perforation of mesocolon/mesorectum 0-8 % (4 %), no-touch isolation technique 36-86 % (67 %), abdominoperineal resection for rectal cancer 0-30 % (17 %), rectal cancer specimen with circumferential margin ≤1 mm 0-19 % (10 %), in-hospital mortality 0-6 % (2 %), anastomotic leak or intra-abdominal abscess 0-17 % (7 %), re-operation 0-17 % (8 %).

CONCLUSION

In colorectal cancer, surgery considerable variations between different centers were found with regard to radicality and oncosurgical quality, suggesting a potential for targeted improvement of surgical technique.

Abdominosacral resection for locally recurring rectal cancer

AIM

To investigate feasibility and outcome of abdominal-sacral resection for treatment of locally recurrent rectal adenocarcinoma.

METHODS

A population of patients who underwent an abdominal-sacral resection for posterior recurrent adenocarcinoma of the rectum at the National Cancer Institute of Milano, between 2005 and 2013, is considered. Retrospectively collected data includes patient characteristics, treatment and pathology details regarding the primary and the recurrent rectal tumor surgical resection. A clinical and instrumental follow-up was performed. Surgical and oncological outcome were investigated. Furthermore an analytical review of literature was conducted in order to compare our case series with other reported experiences.

RESULTS

At the time of abdomino-sacral resection, the mean age of patients was 55 (range, 38-64). The median operating time was 380 min (range, 270-480). Sacral resection was performed at S2/S3 level in 3 patients, S3/S4 in 3 patients and S4/S5 in 4 patients. The median operating time was 380 ± 58 min. Mean intraoperative blood loss was 1750 mL (range, 200-680). The median hospital stay was 22 d. Overall morbidity was 80%, mainly type II complication according to the Clavien-Dindo classification. Microscopically negative margins (R0) is obtained in all patients. Overall 5-year survival after first surgical procedure is 60%, with a median survival from the first surgery of 88 ± 56 mo. The most common site of re-recurrence was intrapelvic.

CONCLUSION

Sacral resection represents a feasible approach to posterior rectal cancer recurrence without evidence of distant spreading. An accurate staging is essential for planning the best therapy.

Incidence, Patterns, and Predictors of Locoregional Recurrence in Colon Cancer

BACKGROUND

Locoregional recurrence (LR) in colon cancer is uncommon but often incurable, while the factors associated with it are unclear. The purpose of this study was to identify patterns and predictors of LR after curative resection for colon cancer.

METHODS

All patients who underwent colon cancer resection with curative intent between 1994 and 2008 at a tertiary referral center were identified from a prospectively maintained institutional database. The association of LR with clinicopathologic and treatment characteristics was determined using univariable and multivariable analyses.

RESULTS

A total of 1397 patients were included with a median follow-up of 7.8 years; 635 (45%) were female, and the median age was 69 years. LR was detected in 61 (4.4%) patients. Median time to LR was 21 months. On multivariable analysis, the independent predictors of LR were disease stage [hazard ratio (HR) for Stage II 4.6, 95% confidence interval (CI) 1.05-19.9, HR for Stage III 10.8, 95% CI 2.6-45.8], bowel obstruction (HR 3.8, 95% CI 1.9-7.4), margin involvement (HR 4.1, 95% CI 1.9-8.6), lymphovascular invasion (HR 1.9, 95% CI 1.06-3.5), and local tumor invasion (fixation to another structure, perforation, or presence of associated fistula, HR 2.2, 95% CI 1.1-4.5). Adjuvant chemotherapy was not associated with reduced LR in patients with either Stage II or Stage III tumors.

CONCLUSIONS

Adherence to oncologic surgical principles in colon cancer resection results in low rates of LR, which is associated with tumor-dependent factors. Recognition of these factors can help to determine appropriate postoperative surveillance.

Surgery for Colorectal Cancer - Trends, Developments, and Future Perspectives

BACKGROUND

Although colorectal surgery is long established as the mainstay treatment for colon cancer, certain topics regarding technical fine-tuning to increase postsurgical recurrence-free survival have remained a matter of debate throughout the past years. These include complete mesocolic excision (CME), treatment strategies for metastatic disease, significance of hyperthermic intraperitoneal chemotherapy (HIPEC), and surgical techniques for the treatment of colorectal cancer recurrence. In addition, new surgical techniques have been introduced in oncologic colorectal surgery, and their potential to provide sufficiently radical resection has yet to be proven.

METHODS

A structured review of the literature was performed to identify the current state of the art with regard to the mentioned key issues in colorectal surgery.

RESULTS

This article provides a comprehensive review of the current literature addressing the above-mentioned current challenges in colorectal surgery. The focus lies on the impact of CME and, in relation to this, on lymph node dissection, as well as on treatment of metastatic disease including peritoneal spread, and finally on the treatment of recurrent disease.

CONCLUSION

Uniformly, the current literature reveals that surgery aiming at complete malignancy elimination within multimodal treatment approaches represents the fundamental quantum leap for the achievement of long-term tumor-free survival.

Long-term survival case of a recurrent colon cancer owing to successful resection of a tumor at hepaticojejunostomy: report of a case

With advances in surgical procedures and perioperative management, hepato-biliary-pancreatic surgery, including hepatectomy and pancreaticoduodenectomy, has been employed for recurrent colon cancer. However, no report has described a case of major hepatectomy with the combined resection of hepaticojejunostomy following pancreaticoduodenectomy for locoregionally recurrent colon cancer. Here, such a case is reported. The patient, a 37-year-old woman, had undergone pancreaticoduodenectomy for lymph node recurrence along the extrahepatic bile duct from cecal cancer. Thirteen months later, a biliary stricture was found at the hepaticojejunostomy site and right hepatectomy was performed. The resected specimen showed a papillary tumor at the hepaticojejunostomy. Based on its histological features, the pathogenesis of this tumor was considered to be intramural recurrence via lymphatic vessels. Although she underwent resection of a lymph node recurrence at her mesentery 12 months later, she has remained well thereafter, without any sign of further recurrence during 5 years of follow-up after hepatectomy.

Long-Term Outcomes of Colon Cancer Patients Undergoing Standardized Technique Operation With Curative Intent

There is no defined standard surgical technique accepted worldwide for colon cancer, especially on the extent of resection and lymphadenectomy, resulting in technical variations among surgeons. Nearly all analyses employ more than one surgeon, thus giving heterogeneous results on surgical treatment. This study aims to evaluate long-term follow-up results of colon cancer patients who were operated on by a single senior colorectal surgeon using a standardized technique with curative intent, and to compare these results with the literature. A total of 269 consecutive patients who were operated on with standardized technique between January 2003 and June 2013 were enrolled in this study. Standardized technique means separation of the mesocolic fascia from the parietal plane with sharp dissection and ligation of the supplying vessels closely to their roots. Patients were assessed in terms of postoperative morbidity, mortality, disease recurrence, and survival. Operations were carried out with a 99.3% R0 resection rate and mean lymph node count of 17.7 nodes per patient. Surviving patients were followed up for a mean period of 57.8 months, and a total of 19.7% disease recurrence was recorded. Mean survival was 113.9 months. The 5- and 10-year survival rates were 78% and 75.8% for disease-free survival, 82.6% and 72.9% for overall survival, and 87.5% and 82.9% for cancer-specific survival, respectively. R1 resection and pathologic characteristics of the tumor were found to be the most important prognostic factors according to univariate and Cox regression analyses. Standardization of surgical therapy and a dedicated team are thought to make significant contributions to the improvement of prognosis.

Difference in Time to Locoregional Recurrence Between Patients With Right-Sided and Left-Sided Colon Cancers

BACKGROUND

Locoregional recurrence rates after curative resection for colon cancer vary widely. Identification of factors associated with locoregional recurrence may help in patient management.

OBJECTIVE

The purpose of this study was to compare time to locoregional recurrence and distribution of locoregional recurrence after curative resection of colon cancer according to primary tumor location and to investigate risk factors for locoregional recurrence of colon cancer.

DESIGN

This was a retrospective observational study.

SETTINGS

This study was conducted at a single institution.

PATIENTS

This study analyzed 1632 patients with colonic adenocarcinoma without distant metastasis who underwent curative resection at the National Cancer Center in Korea between January 2001 and December 2009. The primary end point of the study was time from surgery to locoregional recurrence. The Kaplan-Meier method was used to estimate the cumulative incidence of locoregional recurrence, and the log-rank test was used to test the difference in time to locoregional recurrence between patient subgroups. Cox proportional hazards models were used to investigate the risk factors for locoregional recurrence.

MAIN OUTCOME MEASURES

The time from surgery to locoregional recurrence was compared between patients with right-sided and left-sided colon cancers.

RESULTS

The time to locoregional recurrence was significantly different between patients with right-sided and left-sided colon cancers (HR = 2.35 for right-sided; p < 0.001). The overall 5-year locoregional recurrence rate was 5.7%, and that in patients with right-sided and left-sided colon cancers was 8.5% and 4.1%. Multivariable analysis demonstrated that right-sided location, female sex, T4 disease, lymph node metastasis, and perineural invasion were independent risk factors for locoregional recurrence of colon cancer.

LIMITATIONS

This was a retrospective design and single-institution study.

CONCLUSIONS

Patients with right-sided colon cancers presented with significantly increased risk of locoregional recurrence. Right-sided location, female sex, T4 disease, lymph node metastasis, and perineural invasion are independent risk factors for locoregional recurrence of colon cancer.

Towards safer and appropriate application of endoscopic submucosal dissection for T1 colorectal carcinoma as total excisional biopsy: future perspectives

According to the Japanese Society for Cancer of the Colon and Rectum Guidelines 2014 for the Treatment of Colorectal Cancer, cases with T1 colorectal carcinoma should be considered for additional colectomy with lymph node dissection when histologically complete en bloc resection is endoscopically carried out and when one of the four risk factors listed below is present. These four risk factors are: (i) submucosal (SM) invasion depth ≥1000 μm; (ii) positive vascular invasion; (iii) poorly differentiated adenocarcinoma, signet ring cell carcinoma, or mucinous carcinoma; and (iv) grade 2/3 budding at the deepest part of SM invasion. However, the probability of lymph node metastasis is extremely low if none of these risk factors are present, with the exception of SM invasion depth ≥1000 μm. Consequently, it is assumed that there will be an increasing number of cases where no additional surgery is done, or cases of moderate invasive carcinoma in which endoscopic treatment is carried out to achieve an excisional biopsy, for which complete resection is applicable. In these cases, the preoperative diagnosis, resection techniques such as endoscopic submucosal dissection, features of resected specimens, and the accuracy of pathological diagnosis are all extremely important.

F-18 FDG PET/CT in the assessment of patients with unexplained CEA rise after surgical curative resection for colorectal cancer

PURPOSE

We evaluated the role of quantitative assessment by maximum standardized uptake value (SUVmax) on F-18 fluorodeoxyglucose [F-18]FDG positron emission tomography/computed tomography (PET/CT) in stratifying colorectal cancer (CRC) patients with unexplained carcinoembryonic antigen (CEA) rise after surgical curative resection.

MATERIAL AND METHODS

Forty asymptomatic patients (mean age, 64 ± 12 years) with previous CRC and current serum CEA levels >5 ng/ml underwent [F-18] FDG PET/CT 13 ± 3 months after complete surgical resection. The SUVmax was registered on anastomosis and peri-anastomotic tissue lesions, if present. The patients were followed for 24 ± 9 months thereafter. Re-intervention, evidence of newly discovered distant metastases, and death were recognized as main events and constituted surrogate end points. The receiver-operator-curve (ROC) analysis was performed to estimate the optimal SUVmax cut-off to predict patients at high risk of main events. PET/CT results were then related to disease outcome (overall survival; OS).

RESULTS

The mean SUVmax at the anastomotic site was 6.2 ± 3 (range 2.6-15). At multivariate logistic regression analysis, the anastomotic SUVmax remained as the only significant contributor to the prediction of the events (p = 0.004; OR 1.97). The ROC analysis recognized that the optimal threshold of SUVmax to differentiate patients was 5.7. A worse OS was observed in patients presenting with a SUVmax greater than 5.7 as compared to those having lesser (median survival: 16 vs. 31 months; p = 0.002).

CONCLUSIONS

The quantitative assessment by SUVmax on [F-18]FDG PET/CT may be helpful in patients presenting with unexplained CEA rise after curative resection of CRC, by identifying those at risk of main events.