Curative Resection For Rectal Cancer Research Articles

Impact of Neoadjuvant Therapy on Postoperative Complications in Patients Undergoing Resection for Rectal Adenocarcinoma

Surgical resection continues to be the mainstay of treatment for rectal cancer. Neoadjuvant therapy (chemotherapy and radiation) has also been shown to be efficacious. The impact of preoperative chemotherapy and radiation on postoperative complications is unclear. The purpose of this study is to evaluate the relationship of neoadjuvant therapy on postoperative complications in patients undergoing a resection of rectal cancer. A total of 325 patients who underwent curative resection for rectal cancer from 1984 to 2001 were retrospectively reviewed. Only cases with complete data sets who had undergone surgery at this institution were evaluable (257). The patients were divided into groups based on the operative procedure performed; abdominoperineal resection (APR) versus sphincter-sparing (SS) procedures (LAR/Transanal) and whether or not preoperative chemotherapy or radiation was administered. There was no significant difference between complication rates for APR and SS with 19 per cent and 14 per cent, respectively. The preoperative therapy had no effect on complications after APR. However, the SS group showed 21 per cent of the patients who received radiation had complications compared to 11 per cent in those who did not (P = 0.087). Complications in the SS group included leaks, wound infections, abscess, embolism, cardiac dysrhythmias, and myocardial infarctions. The 30-day mortality was 1.9 per cent for the entire cohort with no clear difference between groups. There was no significant difference in complication rate between APR and SS. In the APR group, neoadjuvant therapy had no impact on the incidence of complications. However, the SS group did show a trend between preoperative chemotherapy and radiation and complication rate. However, this may not outweigh the advantages of preoperative therapy in this setting.

Locally recurrent rectal cancer after curative resection

To determine the incidence of local recurrence, after curative resection for rectal cancer, with the application of total mesorectal excision (TME). During the last ten years, 120 patients underwent curative resection for rectal cancer. As a rule, except for the cases that underwent high anterior resection, TME was applied. In terms of local relapse, routine TME, preoperative radiotherapy, tumour's stage, differentiation grade and number of positive nodes were taken into account. Eight patients (6.7%) presented with local relapse. At 5 years, 91.9% of patients were free of local recurrence and the actuarial disease-free survival was 81%. A significant association between routine TME, tumour's stage, differentiation grade, lymph node invasion and local recurrence was observed. Conversely, preoperative radiotherapy appeared to play no protective role. The curative resection of rectal cancer, with the application of TME, has led to a very low incidence of local relapse during the last few years.

Survival after curative resection for rectal cancer by the end of the 20th century

The aim of this study was to define the survival rates in patients with rectal carcinoma treated with curative resections. Between 1993 and 1998, 54 patients with rectal cancer underwent curative resection by conventional technique. Tumour location, TNM staging and tumour differentiation were evaluated. Among the 54 patients, 14 underwent high anterior resection, 28 low anterior resection, 7 abdominoperineal resection and 5 underwent local excision. Survival rates were calculated using the Kaplan-Meier method and long-range analysis. Five-year survival was 70.4%. The survival rate statistically significantly decreased with increasing TNM tumour stage (p=0.009). Patients with poor differentiation of the tumour had the lowest 5-year survival (33%) compared to patients with moderate (72%) and good (78%) tumour differentiation. Sex and age did not affect survival. Location of the tumour in the distal end of the rectum and mucinous characteristics are poor prognostic factors affecting survival. Curative resection combined with chemoradiotherapy, whenever necessary, is accompanied with acceptable 5-year survival rates.

Effects of calcium on ability of learning and memory in rats exposed to low level lead before and after birth

To investigate the effects of calcium on learning and memory ability of rats exposed to low level lead before and after birth. Wistar dam rats were randomly divided into normal group, lead-contaminated group and lead with Ca group. Corresponding food and water were given to pregnant rats from d 15 of gestation and to young rats till 7 w after birth. The weight of brain and hippocampus, blood lead content, serum calcium content, learning and memory ability of young rats were tested. The blood lead concentrations: lead-contaminated group was the highest, lead with Ca group the second and normal group the lowest. Serum calcium concentrations: normal group and lead with Ca group were both higher than lead contaminated group. Ability of learning and memory: lead with Ca group was better than lead-contaminated group, but poorer than normal group. No differences were found upon the weight of brain and hippocampus in all groups. A minilaparotomy approach for curative resection of rectal cancer may be an ideal alternative approach to conventional laparotomy.

Minilaparotomy approach for curative resection of colorectal cancer

To evaluate the feasibility and safety of a minilaparotomy approach for curative resection of colorectal cancer in comparison with the conventional laparotomy. Seventy-eight patients underwent radical resection for rectal cancer with minilaparotomy during April 2001 to December 2002. The minilaparotomy involved complete resection and a skin incision 2 cm above the link line of left anterior superior iliac spine to pubic symphysis and was about 7-10 cm in length. Another 86 patients who served as control group underwent a similar resection with a conventional laparotomy during the same period. The minilaparotomy approach was successful in all 78 patients. The general status of patients, operative types and histopathological features of tumor were similar in the two groups (P>0.05). Operative blood loss in control group was greater (P<0.001), whereas incision length in minilaparotomy group was significantly shorter than that in conventional laparotomy (9.38 cm compared with 17.32 cm). The operative time, analgesia requirement, first passing flatus,first oral fluids and postoperative hospital stay were significantly shorter in the minilaparotomy group (P<0. 001). In an average 25.4-month follow-up, there were no tumor recurrences in the minilaparotomy group. A minilaparotomy approach for curative resection of rectal cancer may be an ideal alternative approach to conventional laparotomy.

Prognostic significance of both surgical and pathological assessment of curative resection for rectal cancer.

Information on whether surgery has been 'curative' is essential for prediction of prognosis and for selection of patients for adjuvant treatment. The aim of this study was to analyse the prognostic value of surgeons' and pathologists' assessments of tumour clearance in patients with primary rectal cancer who underwent resection. A total of 1550 patients were studied prospectively. Data were collected from reports made by surgeons and pathologists on whether tumour clearance had been 'complete', 'uncertain' or 'incomplete'. The predictive value in relation to outcome after at least 5 years of follow-up was assessed. In patients assessed as having a complete surgical clearance, tumour recurrence developed in 33.3 per cent. For patients with an uncertain or incomplete clearance the recurrence rate was 59.5 and 61 per cent respectively (P < 0.001). The relative risk of recurrence was twice as high when the surgeon and pathologist disagreed than when they both agreed on the complete clearance. Survival in patients with a complete, uncertain or incomplete surgical clearance was 55.3, 23.0 and 10 per cent respectively (P = 0.050). Assessments of tumour clearance were of strong prognostic value in relation to outcome. When the surgeon or pathologist was uncertain, or there was disagreement about the completeness of clearance, the risk of recurrence was similar to that among patients in whom an incomplete resection had been performed.

Curative Surgery for Local Pelvic Recurrence of Rectal Cancer

Background/Aims: Local pelvic recurrence of rectal cancer after radical resection has been associated with morbidity and cancer-related death. This study retrospectively evaluated outcome following curative resection for rectal cancer recurring after surgery on the basis of prognosis, type of procedure and perioperative morbidity. Methods: A total of 85 consecutive patients with local pelvic recurrence of rectal cancer were evaluated. Of these, 43 underwent microscopic curative surgery for local recurrence. Among the 43 patients, 23 underwent surgery alone and 17 received preoperative radiotherapy (40 Gy) (XRT group) in addition to the surgery. Of the 43 patients, 26 were asymptomatic. Results: Curative resection was higher in the recurrences that were associated with implantation, incomplete surgical margin clearance, and intrapelvic lymph node metastasis than in other types of recurrence. With regard to surgical procedure, abdominoperineal resection (APR), with or without sacral resection, was standard following previous sphincter-preserving surgery, while total pelvic exenteration (TPE), with or without sacral resection, was common following previous APR. Local excision was not considered appropriate surgery. There was a high incidence of perioperative morbidity (64%) in patients receiving TPE. Re-recurrence was observed in 18 patients (50%) after curative surgery. After a follow-up of 2 years or more, the local re-recurrence rate was 28%. The overall 5-year survival rate for patients receiving curative resection was 39%, for patients in the XRT group, 51%, and for patients in the surgery-alone group, 24% (p = 0.07). The survival rate in 26 asymptomatic patients was higher than in 17 patients with symptoms, with 5-year survival rates of 62 and 23% (p < 0.05), respectively. The cumulative local control in the preoperative radiotherapy plus en bloc surgery group (XRT group) was significantly better than in the surgery-alone group (p < 0.01), and survival in the XRT group tended to be better than in surgery alone. Conclusions: These results suggest that careful patient selection according to the pattern of recurrence, area of invasion and presence of symptoms is important for successful curative surgery. Aggressive surgery with adjuvant therapy may lead to an improved salvage rate.

Local recurrence after curative excision of the rectum for cancer without adjuvant therapy: role of total anatomical dissection.

The wide variability of reported local recurrence rates after curative resection of rectal cancer without adjuvant therapy may be a consequence of many different factors. However, few studies have investigated the potential effects of such factors on local recurrence by multivariate analysis. The present study examined clinical and tumour characteristics, operation type and operative technique as potential predictors of local recurrence in patients treated by surgery alone. Prospective data were analysed by bivariate and multivariate methods including actuarial survival and proportional hazards regression. Local recurrence (pelvic or pelvic and systemic) was diagnosed in 59 of 596 patients. The 5-year actuarial local recurrence rate was 11.1 (95 per cent confidence interval 8.7-14.3) per cent. Independent predictive factors for local recurrence were: positive nodes (hazard ratio (HR) 5.5, P < 0.01); distal margin of 1 cm or less (HR 3.8, P < 0.01); venous invasion (HR 2.0, P = 0.02) and total anatomical dissection of the rectum (HR 2.0, P = 0.01). There was no difference in local recurrence between patients who had the mesorectum divided and those in whom it was totally excised. Nodal involvement is the most potent predictor of local recurrence. In patients in whom total anatomical dissection is performed, total mesorectal excision confers no additional protection against local recurrence.

Methodology and reporting in studies of local recurrence after curative excision of the rectum for cancer.

Widely varying rates have been reported in the extensive literature published in the English language on local recurrence after curative excision of rectal carcinoma. These variations may be attributable to differences in the case mix of pathological factors influencing recurrence, differences in surgical technique or expertise, differences in the administration of adjuvant therapy and various combinations of these. They may also arise from methodological differences among studies. This paper reviews the adequacy of methodology and reporting in 21 recent studies of local recurrence after curative resection of rectal cancer. Many flaws in reporting and apparent inadequacies in methodology were identified. On an index of 26 criteria examined, eight studies scored no more than 8 and only three studies scored more than 11. To date, the value of reports of local recurrence rates following curative excision of rectal cancer has been limited by inadequacies in documentation and methodology. Suggestions are made for preferred procedures to be followed in the reporting of future studies.

Gender differences in long-term survival of patients with colorectal cancer

Significant differences exist in the immunological response to surgery. This raises the possibility that gender differences exist concerning the outcome after curative colorectal cancer resection. To study this hypothesis, a database of patients with colorectal cancer was analysed prospectively. Some 894 patients were included, 500 (55.9 per cent) were men and 394 (44.1 per cent) were women. Median follow-up was 54.5 months for the entire group and 63.3 months for survivors. The mean(s.e.m.) patient age was 65.3(0.4) years (women 66.1(0.6), men 64.7(0.5) years; P < 0.05). Women lived significantly longer after cancer resection than men (57.8(1.5) versus 52.0(1.3) months; P < 0.05, log rank 0.009). Disease-free survival was significantly longer in women than in men (51.6(1.7) versus 46.0(1.4) months; P < 0.05). Subgroup analysis revealed significant gender differences in Union Internacional Contra la Cancrum (UICC) stages I (n = 195, log rank 0.01) and UICC IV (n = 38, log rank 0.021). Survival analysis after rectal cancer resection revealed significant advantages for women (log rank 0.02), while no gender differences were detected when comparing patients after resection for colonic cancer. Moreover, patients older than 50 years (n = 635) showed significant gender-related survival differences (log rank 0.015). Significant gender differences following curative rectal cancer resection were observed. In women disease-free and overall survival were significantly longer. Whether or not these gender differences are related to gender-specific immune functions or to other gender-related local or systemic factors remains to be determined.

P53 and DCC immunohistochemistry in curative rectal cancer surgery.

In rectal cancer altered expression of p53 or DCC may be indicative of poor patient prognosis. This study determined by immunohistochemistry the tumour status of p53 protein and DCC protein in patients with rectal cancer who had a curative resection and were followed-up prospectively and examined the correlation to clinical and pathology variables. The study included 171 who had a curative resection for rectal cancer: 88 at Concord Hospital (CH) followed up for a mean of 11 years and 83 at Royal Prince Alfred Hospital (RPAH) followed up prospectively for a mean of 4.3 years. Specimens were assessed by immunohistochemical assay of p53 expression ( n=170) and of DCC expression ( n=168). p53 over-expression was demonstrated in 58% of CH tumours and 59% of RPAH tumours. Absence of normal DCC expression was demonstrated in 66% of CH tumours and 52% of RPAH tumours. On both separate and combined analysis of these groups there were no significant associations by univariate analysis between p53 expression or DCC expression or combinations of p53 and DCC expression and the pathology variables: extent of penetration through bowel wall, lymph node involvement, presence of venous invasion, and tumour differentiation. The immunohistochemical p53 and DCC status of rectal tumours was not associated with other clinical or pathology variables, nor predictive of outcome.

Role of total mesorectal excision in curative resection of rectal cancer

Objective To evaluate the effect of total mesorectal excision (TME) on local recurrence rate and 5-year survival rate following radical resection for rectal cancer.

Septic complications and prognosis after surgery for rectal cancer.

The influence of septic complications on long-term prognosis after surgery for rectal cancer is controversial. This study was performed to investigate whether an abdominal or perineal septic complication was associated with rectal cancer recurrence. A total of 228 patients who had undergone curative resection for rectal cancer from 1973 to 1992 were reviewed. The patients were divided into groups of those who developed either an intra-abdominal abscess or a perineal infection after surgery (infection group) and those who did not (noninfection group). There was no clear difference in the overall incidence of tumor recurrence between the infection group (19/53, 36 percent) and the noninfection group (46/175, 26 percent; P = 0.25). However, the incidence of local recurrence was higher in the infection group (12/53, 23 percent) than in the noninfection group (16/175, 9 percent; P = 0.02). This increased risk was restricted to patients with a perineal infection (10/30, 33 percent; P = 0.003 vs. the noninfection group), whereas patients with an abdominal infection (3/24, 13 percent) did not differ from the noninfection group. Patients with a perineal infection after an abdominoperineal resection have an increased incidence of local recurrence. However, there was no association between abdominal sepsis and prognosis after surgery for rectal cancer.

Curative resection for rectal carcinoma: definition influences outcome in terms of local recurrence.

There are wide variations in local recurrence rate following curative surgery for rectal cancer and there are substantial inconsistencies among surgeons regarding the method of defining curative resection. This paper seeks to explore whether defining criteria is one of the important factors driving the variations in outcome. A literature review was undertaken to find all UK-based studies that had data on curative resection and local recurrence rates. The studies were divided into groups with distinct definitions of curative resection for rectal cancer. Meta-analyses were performed to pool the risks of local recurrence by group definition. Statistical tests were used to explore the variation in local recurrence by group. Confounding relationships of age, sex, Dukes stage, length of follow-up and year of study were explored as far as possible given the limitations of the available data. For rectal cancers significant differences were found between the pooled local recurrence risks by group definition (P < 0.01). Meta-regression tests including all the studies indicate that the definition of curative resection is an important predictor of local recurrence. It is suggested that a standardized approach towards defining curative resection and local recurrence may have a significant effect on outcomes in colorectal cancer surgery and would enable comparisons to be made between different series.

Surgeon influenced variables in resectional rectal cancer surgery.

Surgeon influenced variables in rectal cancer surgery were assessed. The literature was reviewed to discuss technical and educational issues that may affect the outcome of surgery for rectal cancer. Particular attention was paid to recently debated topics such as adjuvant therapy, colonic J-pouches, total mesorectal excision, and surgeons' training. In some selected cases, transanal techniques with or without neoadjuvant or adjuvant therapy have improved the success of local excision. The biology of rectal cancer has begun to be understood. However, until a more complete understanding with an appreciation of therapeutic implications has been arrived at, surgeon influenced variables will continue to be of paramount importance. Multiple studies have shown tremendous surgeon variability in the outcome after rectal cancer surgery. Some of the variables that have been shown to be important include tumor-free distal and lateral margins, a total mesorectal excision, and an appropriate anastomosis. It has been well demonstrated that proctectomy with straight coloanal anastomosis compromises function as compared with preoperative levels or healthy controls. These deficiencies are further exacerbated by adjuvant therapy. Significant functional improvements, particularly in the first 12 to 24 months after surgery, have been achieved with use of colonic J-pouch. There are many ways by which the surgeon can optimize curative resection for rectal cancer. Appropriate distal and tumor-free lateral margins with total mesorectal excision should be the goals for all tumors in the lower two-thirds of the rectum. Reconstruction should be performed, whenever technically possible, by a colonic J-pouch. Surgeons should be cognizant of their own practice patterns, volume, capabilities, and very importantly results. These results should be audited frequently and willingly shared with patients.

Comparison of prognosis in cancer of the colon and rectum

To determine whether there is a difference in prognosis between colon and rectal cancer. A prospective audit was conducted of a cohort of consecutive patients presenting to a single colorectal surgeon over an 8-year period, in a teaching hospital colorectal unit. There were 492 patients, 274 with colon cancer and 218 with rectal cancer, followed up to death or for a median of 43 months. Resection of all macroscopic disease was performed where possible by performing, if necessary, en bloc excision of local disease in continuity with adjacent involved structures. There was total mesorectal excision for middle and lower third rectal cancers. The main outcome measures were local recurrence, any recurrence, and survival. Five year survival excluding non-colorectal cancer deaths was 80% for colon cancer and 70% for rectal cancer after curative excision when all stages were grouped together (logrank P=0.25). Survival curves for Dukes' A and B cancers at each site were the same. Dukes' C rectal cancers recurred locally more frequently than colon cancers, but there was no significant difference in survival. With appropriate radical surgery, survival after curative resection of rectal cancer can be as favourable as for colon cancer. Patients with Dukes' C cancers of the rectum are more at risk of local recurrence and this group should be the focus of efforts to improve outcome further.

Risk factors associated with local recurrence after curative resection for rectal cancer

A retrospective study was conducted to identify the factors related to locoregional recurrence in patients who underwent curative resections for primary rectal cancer between January 1986 and April 1994 at Ankara Oncology Hospital in Turkey. A step-wise logistic regression analysis was applied for 116 patients who had complete follow-up. Age, sex, macroscopic size of the lesion, tumor location in the rectum as determined by the distance from the anal verge, obstruction at presentation, tumor histology, lymphatic invasion, venous invasion, stage according to TNM classification, differentiation of the tumor, surgical treatment modality, radical abdominopelvic lymphadenectomy (RAPL), and blood transfusion were used as the clinico-pathologic variables. Locoregional recurrent disease was found after a mean follow-up period of 52 months in 28 (24.1%) patients, while the median recurrence-free period was 12 months. Univariate analysis demonstrated that age, disease stage, tumor grade, obstruction, RAPL, blood transfusion, and venous and lymphatic invasion were significant risk factors (P<0.05); however, using multivariate analysis, an increased risk for the development of locoregional recurrence was found to be associated with: age (P=0.0052), stage (P=0.0379), blood transfusion (P=0.0276), obstruction (P=0.0035), and RAPL (P=0.0069).

Salvage therapy for pelvic recurrence following curative rectal cancer resection.

Pelvic recurrence is a significant problem following curative resection for rectal cancer. Although treatment options include surgery, chemotherapy, radiotherapy, or any combination of these, the role of surgery remains controversial in management of these patients. In this study, we have attempted to define the patient with pelvic recurrence following curative rectal surgery who may benefit from reresection. A review of the prospective colorectal database at Memorial Sloan Kettering Cancer Center (MSKCC) between 1983 and 1991 identified 25 patients who had pelvic recurrence following a curative resection for rectal cancer and 52 patients who had their initial rectal surgery at an outside institution (OI) and their pelvic recurrence treated at MSKCC. Survival was calculated from time of recurrence by the Kaplan-Meier method, and survival comparisons were made by log-rank analysis. There were no differences between the two groups related to age, gender, type of initial surgery, stage, or use of adjuvant therapy. For the MSKCC group, median time to initial recurrence was 18 months, and median survival was 40 months. Recurrence was symptomatic in 17 patients and asymptomatic in 8 patients. Pain and bleeding accounted for more than one-half of symptomatic recurrences. Of the 17 symptomatic recurrences, 11 (65 percent) had relief of preoperative symptoms. There were no clinical or pathologic factors identified of the primary tumor or recurrence that predicted improved survival following salvage therapy. It was not possible to preoperatively determine which patients could undergo curative reresection. For the OI group, median time to recurrence was 13.7 months, and median survival from time of initial recurrence was 31 months. Curative reresection was the only factor that predicted for improved survival compared with noncurative treatment (P = 0.02). A comparison of the two groups revealed that pelvic recurrence was more likely to be reresected for cure in the OI group vs. the MSKCC group (34/51 vs. 9/25; P < 0.02). There was no survival difference between the two groups when comparing curative with noncurative management of these patients. Symptoms from recurrent rectal cancer can be palliated with surgery. The only patients who had a survival benefit were those patients in the OI group whose disease could be completely resected. These differences in reresection rates may be attributable to the presence or absence of available planes for dissection around the recurrence in the OI group, as determined by the method of initial curative resection.

Evaluation and biopsy of recurrent rectal cancer using three-dimensional endosonography.

The value of endorectal ultrasonography for postoperative follow-up of rectal cancer is limited by the inability to distinguish recurrent malignancy from benign lesions, e.g., fibrotic tissue. This study was conducted to investigate the role of three-dimensional (3D) endosonography for evaluation and biopsy of recurrent rectal cancer. Endorectal ultrasonography was performed in routine follow-up program after resection of rectal cancer. 3D volume scans were recorded using a bifocal multiplane 3D transducer (7.5/10 MHz) with a 100 degrees longitudinal and a 360 degrees transversal scan angle. For transrectal ultrasound-guided biopsy of pararectal lesions, a specially designed targeting device was attached to the endoprobe. Overall pararectal lesions were detected in 28 of 163 patients (17 percent) who were undergoing endorectal ultrasonography for follow-up after resection of rectal cancer. 3D image analysis facilitated assessment of suspicious pararectal lesions by contemporary display of three perpendicular scan planes or volume reconstructions of the scanned area. Ultrasound-guided biopsy was performed in all 28 patients with pararectal lesions identified by endorectal ultrasonography. Biopsy revealed recurrent disease or lymph node metastases in seven and two patients, respectively. Benign lesions explained the endosonographic findings in 17 patients. All patients with benign histology still have no evidence of recurrent disease after a median follow-up of seven months. Nonrepresentative material was obtained in only 2 of 28 patients (accuracy, 93 percent). Histology changed the endosonographic diagnosis in 28 percent of cases. 3D endosonography with ultrasound-guided biopsy improves the diagnosis of extramural recurrence after curative resection of rectal cancer. 3D image display allows precise control of the position of the biopsy needle within the target.

Relation between preoperative CT findings in rectal cancer and local recurrence rate. A pilot study.

To identify predictive factors of local recurrence possible to use as criteria for preoperative radiotherapy, we reviewed the CT scans of 51 patients undergoing curative resection for rectal cancer. Seven patients developed local recurrence. The presence of the CT images of spicular structures or a fibrous soft tissue layer around the rectum was related to extrarectal spread with a positive predictive value of 88% (30/34) when compared with the pathology. Six out of 34 cases with these CT findings developed recurrence, compared to only one out of 17 cases without such findings. The recurrence rate was especially high, (4/14), in patients where the abnormal tissue as judged by CT was attached to the perirectal fascia or extended beyond it. CT may be a useful tool for predicting local recurrence by using the perirectal fascia as a diagnostic marker.