Low Local Recurrence Research Articles

Abordaje multidisciplinar en el tratamiento del cáncer de recto: eficacia del tratamiento neoadyuvante

the aim of this study was to assess the impact of neoadjuvant treatment on rectal cancer following involvement of a multidisciplinary team (MDT). between January 2000 and December 2005, 90 patients with rectal adenocarcinoma were evaluated by a MDT and operated on after receiving neoadjuvant treatment with radiochemotherapy (RTCT) -67% were men and 33% were women, with a mean age of 65.04 years (21-83 years). Surgery was low anterior resection in 50% and abdominoperineal amputation in 42.2%. the rate of complications associated with neoadjuvant treatment was 54.4%, with gastrointestinal complications being most frequent. However, this toxicity was tolerated by most patients. It was severe in two cases (2.2%), leading to chemotherapy discontinuation. A histological analysis of specimens showed a complete pathologic response in 10 cases (11.1%) and a partial response (downstaging of T) in 32 cases (35.6%), hence overall response to neoadjuvant treatment was 46.6%. Postoperative complications included anastomotic leakage in 8.3%, perineal wound complications in 34.2%, and urinary disease in 12.2%. The surgical mortality rate was 0%. Local recurrence occurred in 4.4%, and distant metastases were found in 22.2%. Both overall and disease-free survivals were 80 and 64%, respectively. neoadjuvant treatment results in low local recurrence rates and optimal survival rates, with no increase in morbidity or mortality. A systematic evaluation by a MDT in the context of a clinical protocol offers better cure rates.

Factors Influencing the Risk of Local Recurrence after Resection of a Single Brain Metastasis

INTRODUCTION: Local recurrence (LR) of a resected brain metastasis (BM) occurs in up to 46% of patients. Adjuvant whole brain radiation therapy (aWBRT) reduces that incidence. No studies have assessed factors predicting LR risk, especially in the absence of aWBRT. METHODS: Data from 570 patients with a previously untreated single BM resected at M.D. Anderson from 1993 to 2006, who did not receive aWBRT were reviewed. All tumors were preoperatively measured on magnetic resonance imaging. The resection method (en bloc [EBR] versus piecemeal [PMR]) was prospectively noted. LR predictors were assessed using the Cox proportional hazards model. RESULTS: Median age was 58 years; 55% were males; 95% had a Karnofsky Performance Scale score of 70 or greater. The most common primaries were lung (28%), melanoma (21%), renal (19%), and breast (10%). PMR was performed in 201(35%); EBR was performed in 369 (65%). EBR was more common in patients with renal primaries. Tumors undergoing PMR were significantly larger (median, 15.9 cc versus 7.6 cc for EBR). Eighty-four (15%) patients developed LR. Undergoing PMR carried a significantly higher LR risk than EBR (crude hazard ratio [cHR] = 1.7; 95% confidence interval [CI], 1.1–2.6; P = 0.03). Tumors smaller than the median 9.7 cc in volume had a significantly lower LR risk than those 9.7 cc or greater (cHR, 1.7; 95% CI, 1.1–2.6; P = 0.02). Tumors smaller than the 2.6 cc cutoff point obtained through recursive partitioning analysis had a significantly lower LR risk than those 2.6 cc or greater (cHR, 2.4; 95% CI, 1.3–4.3; P = 0.004). The primary type did not significantly predict LR. Of note, however, among the 22 patients with sarcoma, seven developed LR (P = 0.16). In the multivariate analysis, small tumors resected with EBR had a significantly lower LR risk. CONCLUSION: The LR risk of an SBM is influenced by biological factors such as volume and treatment methodologies, such as resection technique. Early institution of aWBRT may be particularly warranted when such negative tumor-related prognostic factors are noted or when treatment-related ones such as PMR are unavoidable.

Oncologic and Functional Outcome of Scapular Chondrosarcoma

The scapula is a common site for chondrosarcoma to occur. There has been disagreement between recent studies documenting the oncologic outcomes in patients with chondrosarcoma of the scapula. The purpose of this study was to investigate both the oncologic and functional outcomes of patients presenting to a large oncology center with primary chondrosarcoma of the scapula. A review of our prospectively collected database was carried out. All patients in the years 1989 to 2004 undergoing surgical resection of primary chondrosarcoma of the scapula were included. We documented patient demographics, whether the patient underwent partial or total scapulectomy, oncologic outcomes including local and systemic recurrence, and functional outcome using the Musculoskeletal Tumor Society (MSTS) 87, MSTS 93, and Toronto Extremity Salvage Score (TESS) rating systems. Twenty-four patients (16 males, 8 females), with a mean age of 44 years (range 18-74 years), met the inclusion criteria. There were no local recurrences. Two patients died of metastatic disease at 23 and 103 months postoperatively. No other patients have developed systemic disease. Sixteen patients underwent partial scapulectomy while eight underwent total scapulectomy. Functional outcome was better in the group undergoing partial scapulectomy with significantly higher MSTS 87 (30.8 versus 16.6), MSTS 93 (89.6 versus 68.3), and TESS (92.6 versus 74.9) scores than the total scapulectomy group. Patients with primary chondrosarcoma of the scapula have an excellent oncologic prognosis with a very low local recurrence and metastatic rate. Functional outcomes are better for patients undergoing partial rather than total scapulectomy.

Impact of neoadjuvant chemoradiotherapy on functional outcomes for patients with uT3 rectal cancer undergoing restorative resection

4098 Background: Our aim is to determine whether neoadjuvant chemoradiation adversely affects functional outcomes for patients with ultrasound stage T3 (uT3) middle and lower third rectal cancer undergoing surgery. Methods: All patients with uT3 middle and lower third rectal cancers who underwent surgery from 1986–2007 were identified from a prospectively maintained cancer database. Prospectively accrued functional outcomes for patients who had neoadjuvant therapy (Group A) were compared with those for patients who did not (Group B). Quality of life (QOL) was measured using SF 36. Results: There were 297 patients in Group A and 153 in group B. Complete response rate was 16.6%. Group A had more males(76 vs 65%, p=0.02) and were younger (59±11.9 vs 66.5 ±12.2 yrs, p<0.001). Group A also had lower tumor distance from anal verge(5.5±2.4 vs 6.2±2.3 cm, p=0.004), greater use of hand-sewn anastomoses (29.9% versus 12.0%, p=0.002) and proximal diversion(38.2% vs19.2%, p<0.001). Tumor differentiation was similar in both groups. Group B had larger tumors (4.5±1.8 vs 2.6±1.7, p=<0.001) with more involved lymph nodes (1, 0–52; 0, 0–22, p=<0.001). Anastomotic leak rate was similar(Grp A: 4 vs 6.8%, p=0.27). Group A had lower local recurrence (12.6% vs. 24.4%, p<0.001) and greater disease free survival rate(75.7% vs. 51.9%, p<0.001). Long term functional outcome were measured by number of day and night time bowel movements, control of solid, liquid and gas and pad use. After adjusting for age, gender, complication and reservoir use, at the time of their most recent evaluation, functional outcomes for patients undergoing restorative resection (Grp A 67.8%, Grp B53.5%) were comparable between groups. Despite the greater proportion of patients with a permanent stoma in Group B, QOL was similar between groups. Conclusion: For uT3 cancer of the mid and lower rectum, neoadjuvant therapy is associated with better oncologic outcomes. With careful surgical technique and judicious use of a reservoir, chemoradiation prior to surgery does not appear to adversely influence functional outcomes. The presence of a permanent stoma does not seem to influence QOL. No significant financial relationships to disclose.

Efficacy of targeted intraoperative radiotherapy (Targit) boost after breast-conserving surgery: Updated results

565 Background: In 1998 we started a phase II study of TARGeted Intraoperative radioTherapy (TARGIT) using the Intrabeam system. We present the updated results of this first group of breast cancer patients treated with breast-conserving surgery where Targit was used as a boost to the tumor bed. Methods: We treated 301 cancers in 300 patients undergoing breast- conserving surgery with no other selection criteria. 97 patients were younger than 51 years, 57% of cancers were between 1 to 2cm, (21% > 2cm), 29% had a grade 3 tumor and 29% were node positive. After lumpectomy, 20Gy was delivered intraoperatively using 50 kV X-rays to the surface of the tumor bed. Postoperative external beam radiotherapy excluded the usual boost. One patient from the original series (Vaidya JS, Baum M, Tobias JS et al. Targeted intraoperative radiotherapy [TARGIT] yields very low recurrence rates when given as a boost. Int J Rad Oncol Biol Phys 66:1335–1338, 2006) did not receive external beam radiotherapy and is now excluded, but remains recurrence free after 51 months. Results: The treatment was well tolerated. At median follow-up of 49 months, 5 patients (1.66%) had local recurrence. The Kaplan-Meier estimate of local recurrence at 5 years is 1.52% (SE=0.76%). This compares very favorably with the 4.3% recurrence rate in boosted patients from the EORTC boost study in which only 8.1% patients were node-positive, as opposed to 29% in our series. Conclusions: It appears that lumpectomy and Targit boost combined with external beam radiotherapy results in an exceptionally low local recurrence rate. This could be attributed to both accurate geometry of the boost and timeliness of the treatment. Irradiation of the tumour bed at the time of surgery might also provide a favorable effect on the micro-environment of any residual disease (Belletti B, Vaidya JS, D'Andrea S, et al. Targeted intraoperative radiotherapy [TARGIT] impairs surgical wound-stimulated breast cancer cell proliferation and invasion. Clin Cancer Res [in press], 2008). These results suggest that not only could Targit be safely used as a boost, but that it is likely to be superior to conventional external boost. Author Disclosure Employment or Leadership Consultant or Advisory Role Stock Ownership Honoraria Research Expert Testimony Other Remuneration Carl Zeiss Carl Zeiss Carl Zeiss Carl Zeiss

A new limb salvage surgery in cases of high‐grade soft tissue sarcoma using photodynamic surgery, followed by photo‐ and radiodynamic therapy with acridine orange

To maintain excellent limb function after tumor resection in patients with high-grade malignant sarcomas, we developed and established a new surgical adjuvant therapy using acridine orange (AO) after intra-lesional or marginal resection while sparing normal tissues of major nerves, vessels or bones adjacent to the tumor. Our AO therapy procedure was combined with photodynamic surgery (PDS), photodynamic therapy (PDT) and radiodynamic therapy (RDT). In this study, 26 patients with primary high-grade soft tissue sarcomas were treated with AO therapy. Results showed a low local recurrence rate (7.7%) and good local recurrence-free rate (88%) after AO therapy. Limb function of all patients was maintained at 100% of ISOLS criteria. Based on these results, we concluded that AO therapy is useful for local control after margin-positive tumor resection and for preserving excellent limb function in patients with high-grade soft tissue sarcomas.

Local excision for more advanced rectal tumors

Over the past 20 years, local excision (LE) of T1 rectal cancer was increasingly established and represents an oncologically established technique. In contrast, the situation for T2 tumors is less clear and has only been investigated in small patient collectives. LE for T2 tumors is thus discussed controversially. Materials and Methods. In addition to our own patients with T2 rectal cancer treated locally (n=40), we have analysed the local recurrence (LR) rates after LE alone (n=124), after immediate conventional radical reoperation (n=29), after adjuvant (chemo)-radiotherapy (n=294) and those after neoadjuvant chemoradiotherapy (nCRT) (n=269) using a PubMed search. Results. LR rates of low-grade T2 tumors after R0 resection by LE alone was 19%. If additional prognostically unfavorable findings were present, the LR rate rose to 52%. By immediate radical reoperation the LR rate was decreased to 7%, whereas that after adjuvant therapy was 16%. In contrast, LE of more advanced tumors after nCRT resulted in LR rates of 9%. Discussion. LE alone of T2 rectal cancer should not be performed, and after adjuvant chemoradiotherapy the risk of developing LR was also high. In cases with unexpected T2 finding after LE, immediate conventional reoperation can represent an adequate oncological therapy, because it reveals comparable results to those obtained by primary radical resection. First results after nCRT followed by LE showed favorable results with low LR rates. If the indication for LE of T2 cancers can be extended to patients after nCRT in the future will have to be determined in prospective mutlticentre studies.

Neoadjuvant Chemoradiation and Local Excision for T2-3 Rectal Cancer

Local excision (LE) of T1 low-risk (G1-2/L0/V0) rectal cancer is an established approach with local recurrence (LR) rates of approximately 5%, whereas LE of > or = T2 high-risk tumors or inadequate resections (R1/RX/R < or = 1 mm) showed high recurrence rates. Because of the favorable results after neoadjuvant chemoradiotherapy (nCRT) and radical surgery of disease that completely responds (CR) with almost absent LR even of T3-4 tumors, an extension of the indication for LE is controversially discussed, and therefore, we assessed this therapeutic option. Including our own data, seven studies about LE after nCRT of cT2-3 tumors (n = 237) were analyzed after a PubMed search for cT categories, tumor height, nCRT regimens, schedule and technique of surgery, complications, freedom of stoma, response rates (ypT0-3), length of follow-up, LR, and metastases. Subgroups that we formed (retrospective vs. prospective/retractor vs. transanal endoscopic microsurgery) showed differences in the distribution of cT categories. However, neither the studies we considered nor our own patients showed LR in CR (ypT0). In addition, patients with ypT1 tumor consistently showed low LR rates of 2% (range, 0%-6%), whereas in ypT2 findings, less favorable LR rates of 6% to 20% were observed, and disease that did not respond to therapy (ypT3) displayed LR rates in up to 42%. Despite of a highly selected patient collective, an extended indication for LE of cT2-3 rectal cancer after nCRT may be considered. The strongest prognostic factors were a CR (ypT0) or responses on submucosa level (ypT1). These first results will have to be confirmed in a prospective trial with an appropriate sample size to ensure high statistical power.

Cosmetic outcome and patient satisfaction after skin-sparing mastectomy for breast cancer with immediate reconstruction of the breast

We conducted a retrospective study to assess the safety, cosmetic outcome, and patients' satisfaction after skin-sparing (SSM) and nipple-sparing mastectomy (NSM) for breast cancer with immediate reconstruction of the breast (SMIBR). The subjects were patients, who underwent SMIBR, breast-conserving surgery (BCS), and total mastectomy (MST) between 2000 and 2004 at Osaka University Hospital. Cosmetic outcome was estimated by 4 reviewers by scoring postoperative photographs of the patients. Patient satisfaction was evaluated with a questionnaire for assessment of quality of life for Japanese breast cancer patients. Of the 74 patients who had undergone SMIBR, 4 developed local recurrences (5%). The local recurrence rate for SMIBR patients was greater than that for BCS (4/178) and MST (3/178, P = .10). The distant recurrence rate was similar for all three types of patients (5% for SMIBR, 5% for BCS, and 9% for MST). The median averaged score by 4 reviewers for the estimated cosmetic outcomes was 7.8 for the SMIBR and 7.5 for the BCS group (P = .20), and for age-adjusted patients, the corresponding scores were 8.2 and 8.0 (P = .70). There was no difference in cosmetic outcome between the SSM and NSM subgroups (P = .09). Average scores for patient satisfaction (social activity, physical aspects, and general condition) were the same for the 3 groups. For body image, the BCS and SMIBR groups had higher scores than the MST group (p < 0.05). Average scores for questions relating to bodily pain and sexual aspects were higher for the BCS than the MST group, but were not different between SMIBR and BCS groups. Similar trends for the 3 groups were observed when patients were divided into subgroups by tumor size or axillary dissection. SMIBR is safe with a comparatively low local recurrence rate and the same distant recurrence rate as for BCS and MST. Moreover, it results in objective cosmetic outcome and patient satisfaction as good as those for BCS, and greater patient satisfaction with body image than that for MST.

The Role of Partial Nephrectomy for the Management of Sporadic Renal Angiomyolipoma

Objectives Angiomyolipoma is a benign renal tumor that has a propensity to grow over time and may cause local complications. Given the benign nature of these lesions, renal-preserving treatments are favored. We evaluated our experience with nephron-sparing surgery for renal angiomyolipoma. Methods We reviewed our institutional nephrectomy registry to identify patients treated with nephron-sparing surgery for renal angiomyolipoma between 1970 and 2004. Patients with a diagnosis of tuberous sclerosis were excluded. Patient demographics, perioperative complications, and postoperative outcomes were recorded. Results We identified 58 patients treated with nephron-sparing surgery for sporadic renal angiomyolipoma, including 44 women and 14 men. The median tumor size was 3.9 cm (range, 0.8–12.5 cm). In 7 patients (12%), several ipsilateral angiomyolipomas were resected, whereas 2 patients were treated with nephron-sparing surgery for bilateral angiomyolipomas. The overall early complication rate was 12%, including a urine leak in 3 (5%) patients. At a median postoperative follow-up of 8 years (range, 1–31 years), 2 (3.4%) patients had radiographic evidence of local recurrence, although no patient experienced symptom recurrence. The median preoperative serum creatinine level was 1.0 mg/dL (range, 0.5–3.9 mg/dL), and the median creatinine level at last follow-up was 1.1 mg/dL (range, 0.6–3.6 mg/dL). No patient developed de novo chronic renal insufficiency after nephron-sparing surgery, including 4 patients treated for angiomyolipomas in a solitary kidney. Conclusions Nephron-sparing surgery for sporadic renal angiomyolipomas offers preservation of renal function and is associated with acceptable complication and low local recurrence rates. The results of this study support nephron-sparing surgery for these lesions.

Concepts and techniques of intraoperative radiotherapy (IORT) for breast cancer

The standard treatment for early breast cancer comprises wide local excision, sentinel lymph node biopsy or axillary lymph node dissection, adjuvant medical treatment and radiotherapy to the whole breast. Many studies suggest that local control plays a crucial role in overall survival. The local recurrence rate is estimated to be 1% per year and varies between 4 and 7% after 5 years and up to 10 to 20% in the long-term follow up. On the basis of low local recurrence rates the concept of whole breast irradiation comes up for discussion, and partial breast irradiation (PBI) is increasingly under consideration. Intraoperative radiotherapy (IORT) is referred to as the delivery of a single high dose of irradiation directly to the tumor bed (confined target) during surgery. PBI (limited field radiation therapy, accelerated partial breast irradiation APBI) is the irradiation exclusively confined to a breast volume, the tumor surrounding tissue (tumor bed) either during surgery or after surgery without whole breast irradiation. Various methods and techniques for IORT or PBI are under investigation. The advantage of a very short radiation time or the integration of the complete radiation treatment into the surgical procedure convinces at a first glance. The promising short-term results of those studies must not fail to mention that local recurrence rates could probably increase and furthermore give rise to distant metastases and a reduction in overall survival. The combination of IORT in boost modality and whole breast irradiation has the ability to reduce local recurrence rates. The EBCTCG overview approves that differences in local treatment that substantially affect local recurrence rates would avoid about one breast cancer death over the next 15 years for every four local recurrences avoided, and should reduce 15-year overall mortality.

Radiotherapy in gastric cancer: a systematic review of literature and new perspectives

Gastric cancer is still a major problem for oncologists. Surgery is the main therapeutic approach; a complete surgical resection is usually necessary to offer potentially curative therapy to patients with adenocarcinoma of the stomach. However, many patients with more locally advanced tumors will experience local and distal recurrences. When a recurrence occurs, only palliative therapy is possible. In operable gastric cancer, both the extent of surgery and the value of adjuvant treatment remain subject to considerable international controversies. To improve local control, surgeons address the role of standardized surgery and of more extended surgery. Radiotherapy appears to improve local control and survival in the adjuvant arms, but perspective randomized trials are scarce and reported over many years. Retrospective experience demonstrated a low local recurrence rate, but was affected by large heterogeneity. However, evidence published in the last few years, improved radiotherapy technologies, better knowledge of the at-risk areas (enabling smaller radiotherapy volumes) and growing interest in neoadjuvant approaches support the role of radiotherapy in gastric cancer.

Patterns of local breast cancer recurrence after skin-sparing mastectomy and immediate breast reconstruction

Background Local recurrence rates after skin-sparing mastectomy and immediate reconstruction are similar to recurrence rates after conventional mastectomy. We investigated the pattern of local recurrences and risk factors associated with them. Methods We identified 206 patients who underwent 210 skin-sparing mastectomies with immediate reconstruction from 1998 to 2006 in our database. Results Eleven patients had local recurrences (5.3%). Nine developed in the quadrant of the corresponding primary tumor. There were no significant differences between patients who recurred and those who did not with respect to tumor size/stage, margin status, estrogen receptor/progesterone receptor/Her2neu status, lymph node metastases, or radiation therapy ( P > .05). Patients with grade 3 invasive tumors or high-grade ductal carcinoma in situ were more likely to recur than patients with grade 1 or 2 invasive tumors or low- or intermediate-grade ductal carcinoma in situ ( P = .0035). Those patients who recurred had a significantly decreased overall survival compared to patients who did not recur ( P = .0006). Conclusions Skin-sparing mastectomy and immediate reconstruction has a low local recurrence rate. Recurrences occur most commonly in the same quadrant as the primary tumor and treatment approaches include surgery, chemotherapy, and radiation therapy. Local recurrence portends a poorer overall survival.

Frozen Section Analysis for Intraoperative Margin Assessment During Breast-Conserving Surgery Results in Low Rates of Re-excision and Local Recurrence

Negative surgical margins minimize the risk of local recurrence after breast-conserving surgery. Intraoperative frozen section analysis (FSA) is one method for margin evaluation. We retrospectively analyzed records of patients who received breast-conserving therapy with intraoperative FSA of the lumpectomy cavity to assess re-excision rates and local control. Records were retrospectively reviewed for individuals who underwent breast-conserving surgery for ductal carcinoma in situ (DCIS) or invasive carcinoma between 1993 and 2003. Inclusion criteria were a minimum of 2 years follow-up and intact tumor at the time of operation. The major outcome measure was local recurrence. The Kaplan-Meier test was used to evaluate local recurrence rates between groups. 290 subjects with an average age of 57.2 years (range 27-89) underwent 292 lumpectomies with FSA. 11.3% had DCIS, 73.3% had infiltrating ductal, 5.8% had infiltrating lobular, and 9.6% exhibited other forms of invasive carcinoma. 70 subjects underwent additional resection at the time of breast surgery, 16 underwent subsequent re-excision, and 17 underwent subsequent mastectomy. At a median follow-up of 53.4 months (range 5.8-137.8), there were six local recurrences (2.74%) in patients who had breast-conserving procedures and two local recurrences in patients who underwent mastectomy. There were no statistically significant associations among local recurrence rate, tumor size, nodal status, or overall stage. Local recurrences were higher in patients with DCIS compared with invasive carcinoma, and tumors >2cm. Intraoperative FSA allows resection of suspicious or positive margins at the time of lumpectomy and results in low rates of local recurrence and re-excision. The low local recurrence rate reported here is comparable to those reported with other margin assessment techniques.

Interventionelle, laparoskopische und offen operative Radiofrequenztherapie maligner Leberläsionen

The growing clinical impact of radiofrequency ablation of liver lesions is reflected by a rapidly increasing number of published papers. Experimental work focuses on factors that reduce the variability of the ablation zone. The Pringle-maneuver plays a key role in this question from a surgeon's perspective. Large single center studies and a meta-analysis show a sharp rise in the rate of local recurrences for tumors larger 3 cm. An open surgical approach is significantly correlated to a low local recurrence rate. Bile duct lesions and intrahepatic abscesses are the most frequent complications. Intraductal bile duct cooling can prevent these complications. Three prospective randomized trials support the use of RFA for small hepatocellular carcinoma. The use of RFA in patients with multiple colorectal metastases is supported by single center studies showing a 3 year survival of > 35%. The favourable cost / benefit ratio will make RFA a part of future multimodal cancer therapy concepts.

Is the circumferential resection margin a predictor of local recurrence after preoperative radiotherapy and optimal surgery for rectal carcinoma?

Circumferential resection margin (CRM) involvement has been correlated with a high risk of developing local recurrence. The aim of this study was to examine the prognostic significance of the CRM involvement after curative resection of rectal cancer in patients treated with preoperative radiotherapy and postoperative chemotherapy where indicated. All patients with rectal cancer treated in a regional central unit from 1996 to 2004 were identified. A surgical resection was performed on 257 patients, and in 229 of these this was assessed as potentially curative. The CRM was examined in all patients. A CRM of < or = 1 mm was considered positive. A positive margin was seen in 19 (8%) patients. At a median follow up of 40 months, only four (1.7%) patients had developed local recurrence, one of whom had a positive CRM. In the four patients the tumour was 5 cm or less from the anal verge. There were no significant differences regarding local recurrence and survival between CRM positive and negative tumours. Rectal cancer managed by combined radiochemotherapy and surgery resulted in a low positive CRM rate and a low local recurrence rate. An involved CRM was not a predictor of local recurrence.

Clinical factors in prediction of prognosis after anterior resection with total mesorectal excision for carcinoma of the rectum

The aim of the study was to estimate the long-term results and the prognostic value of clinical and pathological factors following R0 anterior resection with total mesorectal excision (TME). Ninety-eight consecutive patients with histologically confirmed rectal cancer were studied prospectively with five-year follow-up. Survival was calculated using the Kaplan-Meier method and differences between curves were tested by the log-rank test. Multivariate analysis was performed using the Cox regression model. Recurrence-free survival (RFS) was 63.6%. Mean time of recurrence was 13.8 months (range 3-38). Local recurrence rate was 7.8% with the mean time of 12.7 months (range 3-25). In univariate analysis Dukes' stage (RFS for stage: A=93.2%; B=53.8%; C=26.3%) and preoperative CEA serum level (s-CEA) (for s-CEA<or=5 ng/ml RFS=93.8%; for s-CEA>5 ng/ml RFS=5.9%) significantly influenced survival (P<0.005 and P<0.00001). These parameters were also found to be independent prognostic factors in multivariate analysis (P<0.05 and P<0.00001). Survival was worse in older female patients with low-localised poorly differentiated tumors; however, those variables had not significant impact on prognosis. Neither symptom duration nor mucinous histology was significantly related to survival. Using TME technique a low local recurrence rate resulting in improved survival can be achieved. Apart from clinicopathological staging, elevated s-CEA can identify patients with poor prognosis. In addition to TME adjuvant therapy for this high-risk group should be considered.

Total mesorectal excision versus conventional radical surgery for rectal cancer: a meta analysis

To compare treatment outcomes of total mesorectal excision (TME) with those of conventional radical surgery (CRS) for rectal cancer. Literature reviews were performed with key words, such as rectal cancer, total mesorectal excision, TME on all studies reported on TME versus CRS for rectal cancer between January 1986 to May 2006. According to the same screening criteria, 17 clinical studies were included in our systematic reviews. Two of our co-authors drew the details of trial design, characteristics of participants, results and so on from the studies included. Data analyses were performed by using RevMan 4.2. Sample volume in this Meta analysis was 5267 rectal cancer cases. Quality and quantity analyses were performed within all included studies, prospective studies (prospective nonrandomized studies and multicenter prospective nonrandomized studies) and retrospective studies. The results showed that postoperative survival rate was significantly increased [OR 1.81 (95%CI 1.55-2.11, P<0.00001), OR 1.79 (95%CI 1.49-2.15, P<0.00001) and OR 1.84 (95%CI 1.39-2.45, P<0.00001)] and local recurrence rate was significantly reduced [OR 0.35 (95%CI 0.29-0.43, P<0.00001), OR 0.41 (95%CI 0.32-0.53, P<0.00001) and OR 0.29 (95%CI 0.22-0.39, P<0.00001)] after TME was used. The results of all study analyses agreed with those from prospective studies analyses, in which postoperative mortality was significantly reduced [OR 0.51 (95%CI 0.32-0.87, P=0.007) and OR 0.56 (95%CI 0.33-0.94, P=0.04)] after TME treatment, meanwhile the results of retrospective study analyses indicated that there was no significant difference between TME group and CRS group in postoperative mortality [OR 0.39 (95%CI 0.14-1.10, P=0.07)]. TME was a risk factor for postoperative anastomotic leak according to the results of all included studies and prospective study analyses, but no difference between TME group and CRS group had been found [OR 1.24 (95%CI 0.84-1.83, P=0.29) OR 1.98 (95%CI 0.85-4.61, P=0.11)]. TME is still the standard operative technique for rectal cancer. As compared with CRS, TME results in lower postoperative local recurrence rate and higher survival rate.

Radiofrequency ablation permits an effective treatment for colorectal liver metastasis

Background Radiofrequency ablation (RFA) has become an important adjunct to modern liver surgery. However, scant knowledge on long-term outcome of RFA for colorectal liver metastasis is available, nowadays. Methods This is a prospective clinical study of patients with liver metastasis of colorectal cancer who were treated by RFA between April 1, 1998, and November 30, 2004. Forty-seven patients with 147 liver metastases were treated with RFA in a total of 70 interventions. A metastasis resection was not feasible in 80% of the interventions. All the patients were followed up at regular intervals with contrast-enhanced computed tomography (CT) and laboratory tests including carcinoembryonic antigen (CEA). Results No RFA-related mortality occurred. The median follow-up time after the diagnosis of liver metastasis was 33 months. The RFA-related morbidity was 7%. After the RFA, the expected median overall survival rate is, to date, 39 months. Overall survival rates at 1, 2 and 3 years were 88%, 80% and 57%, respectively. Local recurrence rates reached 8.8% overall and 1.6% for metastasis smaller than 3 cm in diameter. No local recurrence occurred for metastasis smaller than 3 cm in diameter if treated with the newest RFA device. Conclusions Excellent local tumour control was achieved with radiofrequency ablation of small liver metastasis. The expected overall survival rate of patients with RFA for unresectable or non-resected colorectal liver metastasis improved in comparison with the survival rate reported following the natural course (best supportive care) or chemotherapy. The low local recurrence rate of metastases of less than 3 cm challenges the results obtained by the more invasive treatment of conventional liver surgery.

Targeted intraoperative radiotherapy (TARGIT) yields very low recurrence rates when given as a boost

Patients undergoing breast-conserving surgery were offered boost radiotherapy with targeted intraoperative radiotherapy (TARGIT) using the Intrabeam system to test the feasibility, safety, and efficacy of the new approach. We treated 302 cancers in 301 unselected patients. This was not a low-risk group. One-third of patients (98/301) were younger than 51 years of age. More than half of the tumors (172, 57%) were between 1 cm and 2 cm, and one-fifth (62, 21%) were >2 cm; 29% (86) had a Grade 3 tumor and, in 29% (87), axillary lymph nodes contained metastasis. After primary surgery, 20 Gy was delivered intraoperatively to the surface of the tumor bed, followed by external-beam radiotherapy (EBRT), but excluding the usual boost. The treatment was well tolerated. The follow-up ranged from 3 to 80 months (164 and 90 patients completed 2 and 3 years follow-up, respectively). Four patients (1.3%) had local recurrence. The Kaplan-Meier estimate of local recurrence is 2.6% (SE = 1.7) at 5 years. This compares favorably with the 4.3% recurrence rate in boosted patients from the EORTC boost study, in which only 8.1% patients were node-positive, as opposed to 29% in our series. Targeted intraoperative radiotherapy combined with EBRT results in a low local recurrence rate. This could be attributed to both accurate targeting and timeliness of the treatment. These data support the need for a randomized trial to test whether the TARGIT boost is superior to conventional external boost, especially in high-risk women.