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PubMed2006

Can the results of anorectal (abdominoperineal) resection be improved: are circumferential resection margins too often positive?

Carefully executed surgery for rectal cancer has reduced the incidence of local recurrence after restorative resection. Three recent large prospective series have confirmed the perception of a higher positive circumferential resection margin (CRM) rate after abdominoperineal resection. Tumour spread is different for low tumours and the surgical technique of abdominoperineal resection, perhaps better known as anorectal excision, may vary between surgeons. There is a need to redefine the place of anorectal excision and the contribution that can be made by pre-operative chemoradiation and/or extended surgery to reduce local recurrence and increase survival. Defined surgery, validated by histopathological assessment, as applied to TME surgery, would determine whether the perceived higher rates are due to the differences in routes of tumour spread or to surgically related variables. Unnecessary R1 or R2 resections and operative perforation can be minimized by an understanding of the surgical anatomy, the pattern of spread and difference in operative technique between anorectal excision and a low restorative operation. Surgical technique to maximize R0 resection should be based on a detailed understanding of the pelvic fascia and the levator ani and the use of pre-operative imaging to define lines of excision. With the adoption of even lower restorative resection (intersphincteric) there is a need to reassess the method of anorectal excision. This may be achieved by histopathological assessment of CRM positivity and MDT audit to improve results. Clinical trials are essential.

Abdomen↗
PubMed1994

The value of limited resection for "clinical" stage I peripheral non-small cell lung cancer in poor-risk patients: comparison of limited resection and lobectomy by a computer-assisted matched study.

AIM: A computer-assisted retrospective matched study was devised to compare limited resection and lobectomy for non-small cell lung cancer. METHODS: Of 353 patients undergoing operation for "clinical" stage I peripheral non-small cell lung cancer, 16 patients undergoing limited resection (because of poor risk) could be matched satisfactorily with 16 patients undergoing lobectomy (as a standard procedure) on the basis of age, sex, histology, tumor location, and tumor size with computer assistance. RESULTS: No hospital death was observed in the 32 patients. Three of the 16 limited resection patients (19%) developed local recurrence in the same lobe. The 5-year survival rate was 55.5% for limited resection and 73.7% for lobectomy (P = not significant). For tumors more than 2.0 cm in diameter, 3-year survival rate was significantly lower in the limited resection group than in the lobectomy group: 34.3% versus 85.7%, P < 0.05. For adenocarcinoma, limited resection seemed to be more unfavorable than lobectomy: 5-year survival rate, 34.3% versus 75.0%, P = 0.07. CONCLUSIONS: Limited resection offered a good survival rate without hospital death for poor-risk patients; however, lobectomy should be performed for good-risk patients.

Aged↗
PubMed2006

Asymptomatic colorectal cancer with un-resectable liver metastases: immediate colorectal resection or up-front systemic chemotherapy?

BACKGROUND: About 20% of patients with colorectal cancer have synchronous un-resectable liver metastases. Resection of colorectal cancer in patients with moderate-severe symptoms is mandatory before starting chemotherapy. Surgical treatment of asymptomatic colorectal cancers is still a matter of discussion. METHODS: From January 2000 to December 2004, we prospectively collected data on 35 consecutive patients who were treated straightaway by chemotherapy without primary tumor resection. All patients underwent FOLFOX6 as first-line chemotherapy. The aim of the study was to evaluate the rate of surgical complications related to un-resected colorectal tumor. RESULTS: The mean interval between diagnosis and start of chemotherapy was 23.1 days (95% CI: 17.3-28.8). Fifteen of the 35 patients (42.9%) were down-staged to surgery; the mean interval between chemotherapy start and colon-rectum cancer resection was 6.5 months (95% CI: 5.5-7.5). None of them developed complications related to the primary tumor during chemotherapy. Of the other 20 patients who did not undergo any curative surgery, 16 received a second line chemotherapy and 10 a third line: six patients are alive and without intestinal symptoms (mean follow up 22.5 months, 95% CI: 11.2-33.9). Only one patient (2.8%) developed clinical signs of intestinal occlusion 5.6 months from the start of chemotherapy and required urgent colostomy. CONCLUSIONS: The rate of complications related to the non-resected colorectal tumor is very low using oxaliplatin as first line chemotherapy. Non-operative management of asymptomatic colorectal cancers with un-resectable liver metastases is a safe approach.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1998

Interrelationships of clinical outcome, length of resection, and energy cost of walking after prosthetic knee replacement following resection of a malignant tumor of the distal aspect of the femur.

The relationships between the functional score according to the system of the International Society of Limb Salvage, the extent of resection, energy cost of walking, and gait characteristics were studied in thirty-six patients who had had segmental knee replacement after resection of a malignant tumor of the distal aspect of the femur. The mean free-walking velocity was 62.3 meters per minute (79 per cent of normal), which was a result of decreases in both cadence and stride length. The mean net energy cost during walking was 35 per cent greater than that of normal controls and correlated with the percentage of the femur that had been resected. All patients had decreased single-limb support time on the affected side compared with the unaffected side. There was a weak correlation between the asymmetry of the single-limb support time and the percentage of the femur that had been resected. The mean extensor torque of the affected knee was 30 per cent that of the unaffected knee when one head of the quadriceps muscle had been excised, 19 per cent when two heads had been excised, 4 per cent when three heads had been excised, and 1 per cent when four heads had been excised. The patients who had had an extra-articular resection had lower mean extensor and flexor torques at the knee compared with those who had had an intra-articular resection. The asymmetry of the single-limb support time was inversely related to the residual extensor and flexor torques. The overall score according to the system of the International Society of Limb Salvage ranged from 17 to 29 points (mean, 24.6 points; 82 per cent of normal). The net energy cost, percentage of maximum aerobic capacity, and asymmetry of the single-limb support time had significant negative correlations with the overall functional score. Multivariate analysis showed that the overall functional score and the percentage of the femur that had been resected were the two most important factors that predicted the net energy cost. To our knowledge, this is the first objective validation of the functional score according to the system of the International Society of Limb Salvage. As the net energy cost can be predicted from universally available, inexpensive measures, investigators can easily use it as a clinical and research tool to evaluate prosthetic performance and to assess operative outcome.

Adolescent↗
PubMed2006

Survival benefit in patients after palliative resection vs non-resection colon cancer surgery.

AIM: To evaluate survival in patients undergoing palliative resection versus non-resection surgery for primary colorectal cancer in a retrospective analysis. METHODS: Demographics, TNM status, operating details and survival were reviewed for 67 patients undergoing surgery for incurable colorectal cancer. Palliative resection of the primary tumor was performed in 46 cases in contrast to 21 patients with non-resection of the primary tumor and bypass surgery. Risk factors for postoperative mortality and poor survival were analyzed with univariate and multivariate analyses. RESULTS: The two groups were comparable in terms of age, gender, preoperative presence of ileus and tumor stage. Multivariate analysis showed that median survival was significantly higher in patients with palliative resection surgery (544 vs 233 d). Differentiation of the tumor and tumor size were additional independent factors that were associated with a significantly poorer survival rate. CONCLUSION: Palliative resection surgery for primary colorectal cancer is associated with a higher median survival rate. Also, the presence of liver metastasis and tumor size are associated with poor survival. Therefore, resection of the primary tumor should be considered in patients with non-curable colon cancer.

Adult↗
PubMed2001

[Resection and reconstruction of the inferior vena cava for major hepatic resection].

The inferior vena cava (IVC) is partially or segmentally resected in major hepatic resection for malignant hepatic tumors in case of possible direct invasion to the IVC wall or IVC tumor thrombosis. The reconstruction methods of the IVC are divided into three categories depending on the degree of IVC resection: simple suture; patch repair; and segmental replacement. In segmental replacement, a synthetic material such as a cylindrical expanded polytetrafluoroethylene (ePTFE) grafts is widely utilized as a substitute. The total hepatic vascular exclusion technique is usually necessary in concomitant resection of the suprahepatic IVC. When a longer duration of hepatic vascular exclusion is required to resect and reconstruct the suprahepatic IVC and hepatic vein confluence, in situ hypothermic perfusion, the ante situm technique, or ex vivo bench surgery must be applied. When an ePTFE graft is replaced in the resected IVC, a Carrel patch of the IVC is used for the hepatic vein orifice to maintain anastomotic patency. Alternatively, the hepatic vein can be reanastomosed to an inferior vena caval segment transpositioned from the intact infrahepatic IVC portion by replacing the resected infrahepatic IVC with an ePTFE graft.

Blood Vessel Prosthesis↗
PubMedDate not supplied

Repeated resections of extrahepatic metastases after hepatic resection: an aggressive approach to hepatocellular carcinoma.

Survival following curative hepatic resection for hepatocellular carcinoma is limited by a high incidence of recurrence. Resection of extrahepatic recurrences has been shown to prolong survival in selected patients. We report two cases in whom repeated resections of extrahepatic metastases achieved good palliation and survival. The first patient had cerebral, pulmonary and splenic metastases that appeared more than four years following an extended left hepatectomy for a 4-cm hepatocellular carcinoma. Resection of the metastases in the three organs was performed in sequence, and the patient remained alive and asymptomatic 12 months after the metastatic recurrence. The second patient developed pulmonary metastases after an extended right hepatectomy for a 16-cm hepatocellular carcinoma. Following two resections of pulmonary metastases, he was alive and disease-free for seven years. These two cases illustrate that an aggressive surgical approach of repeated resections of extrahepatic recurrences after curative resection of hepatocellular carcinoma can result in long-term survival in selected patients.

Adult↗
PubMedDate not supplied

Successful downstaging by S-1-based chemotherapy followed by surgical resections for gastric carcinoma with extensive distant lymph node metastasis - report of two cases and a review of cases with surgical resection after downstaging by S-1-based chemotherapy.

We report two cases of gastric carcinoma with successful downstaging using S-1-based chemotherapy followed by surgical resection, which enabled us to confirm the histological effect of chemotherapy. These patients were associated with extensive distant lymph node metastases for which curative resections were unlikely to be performed. We performed anticancer chemotherapy using S-1 with or without concomitant administration of cisplatin in a neoadjuvant setting. After the successful downstaging of these metastatic gastric carcinomas evaluated by imaging analyses, the patients underwent surgical resections. Effect of the chemotherapy was confirmed by the histological analyses. These cases provide further evidence, suggesting that S-1-based chemotherapy enabled downstaging of stage IV gastric carcinoma associated with distant extensive lymph node metastasis and consequently the following possible curative resections. The review of 16 cases of S-1-based chemotherapy followed by surgical resections indicated that, although downstaging may not be expected when N3 lymph node metastases are evident, the S-1-based chemotherapeutic regimens were effective in short cycles for patients in whom potential curative resection is expected. Survival benefit of downstaging followed by surgical resection, however, remains to be further elucidated.

Adenocarcinoma↗
PubMedDate not supplied

Hepatocellular carcinoma: surgical resection versus surgical resection combined with pre- and post-operative locoregional immunotherapy-chemotherapy. A prospective randomized study.

Hepatocellular carcinoma remains a disease with poor prognosis. Liver resection, although the optimal method of management, is associated with a high incidence of intrahepatic tumour recurrence ranging between 50-70%, 12 to 18 months following surgery. This study assesses prospectively the results of liver resection as compared to liver resection combined with pre- and post-operative locoregional chemotherapy-immunotherapy in 40 patients suffering from hepatocellular carcinoma. Patients were randomly assigned to two groups. Group A (20 patients) had liver resection only, while Group B (20 patients) had liver resection combined with pre- and past-operative targeting locoregional chemotherapy-immunotherapy. Five (5) patients died in total: two from Group A and two from Group B, during the first 30 days following surgery due to reasons related to the procedure (post-operative liver failure in three, pulmonary embolism in one). The remaining patient from Group A died 10 months following liver resection due to intrahepatic tumour recurrence. From Group A, 17 patients are alive from 3 to 26 months after surgery. Of the 17 alive patients, 10 are free of disease and 7 show intrahepatic recurrence. Thus, tumour intrahepatic recurrence occurred in 8 patients of group A. From Group B, all 18 patients are alive and free of disease from 4 to 27 months after surgery. No patient died because of the disease nor has any patient shown intrahepatic tumour recurrence. As a conclusion of the present results, liver resection combined with pre- and post-operative targeting locoregional immunotherapy-chemotherapy appears to offer substantial advantages for patients undergoing surgery because of hepatocellular carcinoma.

Adult↗
PubMedDate not supplied

Segmental liver resections, present and future-caudate lobe resection for liver tumors.

BACKGROUND/AIMS: Resection of the caudate lobe of the liver is difficult to perform because of a deep location and an adjacency to the major vessels. METHODOLOGY: A total of 30 patients with hepatocellular carcinoma (HCC) originating in the caudate lobe underwent hepatic resection. The lobe was classified to Spiegel's portion, the process portion, and the caval portion. The operative procedure undertaken was chosen on the basis of tumor location as well as hepatic function of each patient. RESULTS: In 14 patients who had an HCC located at Spiegel's portion or the process portion, the tumor was removed by local resection of the caudate lobe (n = 10), or by resection combined with lobectomy (n = 2) or subsegmentectomy (n = 2). In 16 patients with an HCC at the caval portion, caudate lobe resections with preparatory lobectomy (n = 6), segmentectomy (n = 1), or subsegmentectomy (n = 4) were performed. In the other 5, isolated total or partial resection of the caudate lobe was carried out because of the presence of severe cirrhosis. All operations were defined as curative, but produced two operative deaths due to liver failure. The cumulative rate of overall survival was 41% at 5 years after surgery. CONCLUSIONS: Caudate lobe resection for HCC can be performed even in cirrhotic patients with a favorable surgical outcome.

Carcinoma, Hepatocellular↗
PubMed2002

Genetic and histological assessment of surgical margins in resected liver metastases from colorectal carcinoma: minimum surgical margins for successful resection.

HYPOTHESIS: There have been few reports on the minimum surgical margins (SMs) required for successful liver resection in patients with colorectal metastases. This minimum requirement may be narrower than the previously recommended margin of 10 mm. OBJECTIVES: To identify the minimum margins by assessing the presence of micrometastases around the tumor using genetic and histological techniques, and to investigate whether SMs are associated with patterns of tumor recurrence or patient survival. DESIGN: Prospective and retrospective studies. SETTING: Tertiary referral cancer center. PATIENTS AND METHODS: Fifty-eight patients who underwent 62 liver resections for hepatic metastasis from colorectal cancer between December 1, 1996, and November 30, 2000, were included in the study. Tissue samples taken from the tumor, surrounding liver parenchyma, and Glisson pedicle near the tumor were tested for K-ras and p53 mutations using the mutant allele-specific amplification method. For the retrospective study on patient outcomes, 194 patients who had undergone liver resections between 1980 and 2000 were analyzed according to their SMs. RESULTS: Of the 62 sets of samples from liver metastases, 39 were positive for K-ras and p53 gene mutations or both. Micrometastases in the liver parenchyma surrounding colorectal metastases were present in 2.0% (4/199) of tested samples and were located within 4 mm of the tumor border. Micrometastases via Glisson pedicle were more common (14.3% [3/21]), but these were also confined to a short distance from the tumor edge (</=5 mm). Of the 5 micrometastases detected by genetic analysis, only 2 were confirmed by histopathological examination. The analysis of patient outcomes demonstrated that the incidence of cut-end recurrence (relapse in the bed of resection) decreased from 20.0% to a range of 5.6% to 7.5% when the SM is 2 mm or more. The incidence of definite cut-end recurrence in patients with SMs less than 2 m, 2 to 4 mm, and 5 mm or wider was 13.3% (6/45), 2.8% (1/36), and 0% (0/102), respectively. The SM was not a significant prognostic factor in patient survival. CONCLUSIONS: Micrometastases around liver tumors are not common, and most are confined to the immediate vicinity of the tumor border. We propose an SM of 2 mm as a clinically acceptable minimum requirement, which carries approximately a 6% risk of margin-related recurrence. Because liver resection provides the only chance of cure, complete removal of the tumor with a minimum margin is justified when technically unavoidable because of the size, location, number of tumors, or successive resections.

Adult↗