Upper Rectal Cancer Research Articles

The effect of MRI or PET fusion in radiotherapy treatment planning on the pathological complete response rate in rectal adenocarcinoma.

523 Background: A pathological complete response rate of 10% to 30% has been noted to occur following preoperative chemoradiation with CT-based treatment planning in patients with rectal cancer. Fusion of the treatment planning CT with other imaging modalities like MRI or PET may help identify tumor location and improve tumor coverage. This retrospective study sought to evaluate the effect of adding MRI or PET imaging to CT-based treatment planning and its impact on pathological complete response rates in patients with rectal cancer. Methods: A retrospective analysis was performed on 39 patients, who received neoadjuvant chemoradiation for rectal adenocarcinoma from February 2009 to September 2013. Patients were divided into two groups. The first group was treated using CT-only based treatment 3D-Conformal or IMRT planning (n=9) and the second was treated using either PET or MRI fusion with the simulation CT scan (n=30). Patients were treated to a total of 5,040 cGy in 28 fractions. Pathological complete response rates (ypT0N0M0) were assessed using postoperative pathologic reports following resection. Results: 39 patients with a median age of 62 received preoperative chemoradiation with an interval to surgery ranging from 34-162 days and a median of 70 days. Patients treated with PET or MRI fusion treatment planning showed a complete pathological response rate at the primary site of 60% and a complete lymph node pathological response rate of 70.83% compared to 22.22% at the primary site and 66.66% at lymph node sites in patients with CT-only treatment planning. In patients treated using MRI or PET fusion, middle rectal cancer showed the best complete pathological response rate at 80%, followed by lower rectal cancer at 41.66%, and upper rectal cancer at 37.5%. Conclusions: Although the sample size was small, utilization of MRI or PET fusion resulted in a higher pathological complete response rate when compared to CT-only based treatment planning, especially in middle rectal cancers. Further studies are needed to accurately identify those patients with a complete pathologic response which may ultimately alter their treatment course.

Location of rectal cancer as determined using rectal magnetic resonance imaging, and its relationship with pulmonary metastasis.

The aim of this study was to evaluate the accuracy of 3-T magnetic resonance imaging (MRI) in locating rectal cancer, and to determine whether tumor location correlates with the incidence of pulmonary metastasis. A total of 146 patients with confirmed rectal adenocarcinoma underwent 3-T rectal MRI, and abdominal and chest computed tomography (CT) within 2 weeks of the endoscopic examination. We reviewed the distance between the mass and the anal verge recorded in the endoscopic reports of these patients. Two radiologists evaluated the same distance on MRI scans by using picture archiving and communications systems. Multiple factors including the tumor location, primary tumor and lymph node stage, lung and liver metastasis, pathologic differentiation, and the carcinoembryonic antigen level were evaluated. The correlation between tumor location on MRI and endoscopy was assessed, and significant factors influencing pulmonary metastasis were identified using multivariate logistic regression analysis. There was a statistically significant correlation between the tumor location established using MRI and the actual location recorded during endoscopy. The incidence of pulmonary metastasis was significantly higher in patients with lower rectal cancer (11/17, 65%) compared to those with upper rectal cancer (6/17, 35%; p<0.05). Factors associated with pulmonary metastasis were tumor location and the presence of liver metastasis. The accurate tumor location could be indicated using 3-T rectal MRI. Pulmonary metastasis occurred more frequently in patients with lower rectal cancer than in those with upper rectal cancer.

Adjuvant Radiation Therapy May Be Necessary for High-Risk Patients With Stage II or III Upper Rectal Cancer After Total Mesorectal Excision

Adjuvant Radiation Therapy May Be Necessary for High-Risk Patients With Stage II or III Upper Rectal Cancer After Total Mesorectal Excision

Effect of previous abdominal surgery on short-term outcomes following laparoscopic colorectal surgery.

653 Background: The impact of previous abdominal surgeries on the need for conversion to open surgery and on short-term outcomes during/after laparoscopic colorectal surgery was retrospectively investigated. This retrospective cohort study was conducted from May 2004 through October 2012. This study was conducted at Tokushima University Hospital and Ehime Prefectural Central Hospital. Methods: A total of 145 consecutive patients who had undergone laparoscopic resection of the sigmoid colon and upper rectum were classified as not having previous abdominal surgery (NPAS group, n = 123) or as having previous abdominal surgery (PAS group, n = 22). Short-term outcomes were assessed between the two groups. Results: The population of previous abdominal surgery consisted of 6 appendectomy, 3 gastrectomy for gastric ulcer, 2 nephrectomy, 2 peritonitis and 11 others (2 duplication). There were no significant differences in age, gender, BMI, tumor location, tumor size, Stage, operating time, blood loss and number of lymph node harvest between the two groups. The conversion to open surgery was performed in 1 patient (4.5%) in the PAS group and 6 patients (4.9%) in the NPAS group. The intraoperative inadvertent enterotomy occurred in 1 patient in the NPAS group. There was no difference in postoperative morbility between the two groups. In the NPAS group, anastomotic leakage was observed in 3 cases. Ileus was observed in one case in the NPAS and none in the PAS. Postoperative hospital stay was 14 days in the PAS group and 16 days in the NPAS group. Conclusions: Short-term outcomes following laparoscopic surgery for sigmoid colon and upper rectal cancer with previous abdominal surgery are acceptable.

Extended Low Hartmann Operation with Total Mesorectal Excision - Optimal Surgical Treatment in Stage IV Mid and Upper Rectal Cancer

Background: The main surgeries that can be performed in upper and mid rectal cancer are low anterior rectal resection (LAR), lateral colostomy (LC), and extended Hartmann operation with mesorectal excision (EHO). Compared to lateral colostomy, EHO is a curative surgery; it also takes a shorter time to perform and has a lower mortality compared with LAR. Objective: The aim of this study was to analyze the postoperative surgical complications in patients who underwent LAR, LC, or EHO. Methods: The study is a prospective analysis based on a Surveillance protocol for patients with liver metastases of colorectal origin used in First Surgical Oncology Unit, Regional Institute of Oncology IaAŸi, Romania. The postoperative complications occurring within 60 days postoperatively were analyzed. Results: In the interval June 2012 – May 2014, 87 patients were diagnosed with upper and mid-rectal cancer and liver metastases; LAR was performed in 18 patients, LC in 19 patients and in 50 patients EHO with pelvic drainage abdominally exteriorized or perineally (37 and 13 patients, respectively). The postoperative complications related to surgical wound, stoma, pelvic abscess, postoperative bleeding, prolonged postoperative ileus, anastomotic leakage, reinterventions, readmissions, and mortality were analyzed. A higher rate of pelvic abscesses was found in EHO patients (24%, n=12), of which 9 patients (18%) required reinterventions for drainnage of pelvic fluid collection; all these patients had pelvic drainage exteriorized abdominally. No presacral abscesses were recorded in patients with pelvic drainage exteriorized perineally. Conclusions: Extended Hartmann Operation (EHO) remains a safe technique, that shares some indications with LAR and LC; however, it is associated with a higher percentage of pelvic abscesses and reinterventions that can be avoided by postoperative perineal drainage of the presacral space

A Distribution Weighted Prognostic Scoring Model for Node Status in Advanced Rectal Cancer

PurposeThere are various lymph node-based staging systems. Nevertheless, there is debate over the use of parameters such as the number of involved lymph nodes and the lymph node ratio. As a possible option, the distribution of metastatic lymph nodes may have a prognostic significance in rectal cancer. This study is designed to evaluate the impact of distribution-weighted nodal staging on oncologic outcome in rectal cancer.Materials and MethodsFrom a prospectively maintained colorectal cancer database of our institution, a total of 435 patients who underwent a curative low anterior resection for mid and upper rectal cancer between 1995 and 2004 were enrolled. Patients were divided into 3 groups according to the location of apical metastatic nodes. A location-weighted prognostic score was calculated by a scoring model using a logistic regression test for location based-statistical weight to number of lymph nodes. All cases were categorized in quartiles from lymph node I to lymph node IV using this protocol.ResultsThe location of lymph node metastasis was an independent factor that was associated with a poor prognostic outcome (p<0.001). Based on this result, the location-weighted-nodal prognostic scoring model did not show lesser significant results (p<0.0001) in both overall survival and cancer-free survival analyses.ConclusionThe location of apical nodes among the metastatic nodes does not have a lesser significant impact on oncologic result in patients with advanced rectal cancer. A location-weighted prognostic scoring model, which considered the numbers of involved lymph nodes as the rate of significance according to the location, may more precisely predict the survival outcome in patients with lymph node metastasis.

Magnetic resonance imaging in rectal cancer: A surgeon’s perspective

Magnetic resonance imaging (MRI) in rectal cancer was first investigated in 1999 and has become almost mandatory in planning rectal cancer treatment. MRI has a high accuracy in predicting circumferential resection margin involvement and is used to plan neoadjuvant therapy. The accuracy of MRI in assessing mesorectal lymph nodes remains moderate, as there are no reliable criteria to assess nodal involvement. MRI seems to be good in assessing peritoneal involvement in upper rectal cancer; this however has been assessed in only a few studies and needs further research. For low rectal cancers, mesorectum is thin at the level of levator ani especially in relation to prostate; so predicting circumferential resection margin involvement is not easy. However high spatial resolution coronal imaging shows levator muscles, sphincter complex and intersphincteric plane accurately. This is used to stage low rectal tumors and plan plane of surgery (standard surgery, intersphincteric resection, Extralevator abdominoperineal resection). While most centres perform MRI post chemoradiotherapy, its role in accurate staging post neoadjuvant therapy remains debatable. THe role of Diffusion weighted MRI post neoadjuvant therapy is being evaluated in research settings.

Single incision laparoscopic colectomy for colorectal cancer: comparison with conventional laparoscopic colectomy.

PurposeThe aim of this retrospective study was to evaluate the feasibility of single incision laparoscopic surgery (SILS), and to compare the short-term surgical outcomes with those of conventional laparoscopic surgery for colorectal cancer.MethodsForty-four patients who underwent SILS were compared with 263 patients who underwent conventional laparoscopic surgery for colorectal adenocarcinoma between November 2011 and September 2012.ResultsIn the SILS group, eleven cases (25.0%) of right hemicolectomy, 15 (34.1%) anterior resections, and 18 (40.9%) low anterior resections were performed. Additional ports were required in 10 rectal patients during SILS operation. In the 32 patients with rectosigmoid and rectal cancer in the SILS group, patients with mid and lower rectal cancers had a tendency to require a longer operation time (168.2 minutes vs. 223.8 minutes, P = 0.002), additional ports or multiport conversion (P = 0.007), than those with rectosigmoid and upper rectal cancer. Both SILS and conventional groups had similar perioperative outcomes. Operation time was longer in the SILS group than in the conventional laparoscopic surgery group (185.0 minutes vs. 139.2 minutes, P < 0.001). More diverting stoma were performed in the SILS group (64.7% vs. 24.2%, P = 0.011). Multivariate analysis showed that tumor location in the rectum (95% confidence interval [CI], 1.858-10.560; P = 0.001), SILS (95% CI, 3.450-20.233; P < 0.001), diverting stoma (95% CI, 1.606-9.288; P = 0.003), and transfusion (95% CI, 1.092-7.854; P = 0.033) were independent risk factors for long operation time (>180 minutes).ConclusionSILS is a feasible, not inferior treatment option for colorectal cancer, and appears to have similar results as standard conventional multiport laparoscopic colectomy, despite the longer operative time.

An alternative technique to achieve mesorectal excision in upper rectal cancer in a narrow pelvic cavity

PURPOSE: Appropriate partial mesorectal excision (PME) is extremely important for prevention of local recurrence in rectal cancer. However, it is not always easy to conduct PME in the narrow pelvic cavity. We used a new surgical technique that involves a rectal transection followed by PME. MATERIAL AND METHODS: After rectal mobilization in the layer targeted for total mesorectal excision, only the rectal wall was bluntly dissected at an appropriate distance from the tumor. Initial transection of the rectum draws the rectum toward the anal side so that the mesorectum can be excised in a good visual field. Excision of the mesorectum was easy, and it could be resected in a short time. RESULTS: This technique was conducted on twenty patients with upper rectal cancer and on eight patients with rectosigmoid cancer. Separation of the rectal wall was comparatively easy. The average distance from the rectal stump to the distal mesorectum in the freshly resected specimen was 15 mm, indicating satisfactory PME. CONCLUSION: This easily performed method is a promising procedure for achieving sufficient PME in upper rectal cancer. Scripta Scientifica Medica 2013; 45(4): 56-58.

Electroacupuncture Reduces Duration of Postoperative Ileus After Laparoscopic Surgery for Colorectal Cancer

We investigated the efficacy of electroacupuncture in reducing the duration of postoperative ileus and hospital stay after laparoscopic surgery for colorectal cancer. We performed a prospective study of 165 patients undergoing elective laparoscopic surgery for colonic and upper rectal cancer, enrolled from October 2008 to October 2010. Patients were assigned randomly to groups that received electroacupuncture (n = 55) or sham acupuncture (n = 55), once daily from postoperative days 1-4, or no acupuncture (n = 55). The acupoints Zusanli, Sanyinjiao, Hegu, and Zhigou were used. The primary outcome was time to defecation. Secondary outcomes included postoperative analgesic requirement, time to ambulation, and length of hospital stay. Patients who received electroacupuncture had a shorter time to defecation than patients who received no acupuncture (85.9 ± 36.1 vs 122.1 ± 53.5 h; P < .001) and length of hospital stay (6.5 ± 2.2 vs 8.5 ± 4.8 days; P = .007). Patients who received electroacupuncture also had a shorter time to defecation than patients who received sham acupuncture (85.9 ± 36.1 vs 107.5 ± 46.2 h; P = .007). Electroacupuncture was more effective than no or sham acupuncture in reducing postoperative analgesic requirement and time to ambulation. In multiple linear regression analysis, an absence of complications and electroacupuncture were associated with a shorter duration of postoperative ileus and hospital stay after the surgery. In a clinical trial, electroacupuncture reduced the duration of postoperative ileus, time to ambulation, and postoperative analgesic requirement, compared with no or sham acupuncture, after laparoscopic surgery for colorectal cancer. ClinicalTrials.gov number, NCT00464425.

Secondary Radiation Doses of Intensity Modulated Radiation Therapy in Patients With Lung and Liver Cancer

than for IMRT (p<0.001, respectively). VSB30 and VSB40 were significantly reduced in the IMRT (p<0.001, respectively). In middle and low rectal cancer, IMRT significantly increased VSB15 and VSB20 (increasing volume: middle38 50 cc, 35 31 cc, low 38 39 cc, 37 31 cc) whereas reduced only VSB40 compared with 3D-CRT (reducing volume: middle12 12 cc, low11 12 cc). In upper rectal cancer, however, IMRT reduced VSB30 and VSB40 (reducing volume: 24 19 cc, 13 7.5 cc), and increased only VSB20 compared with 3D-CRT (Increasing volume: 26 24.8 cc). The mean dose of bladder between two plans did not differ significantly. Conclusions: There is no difference target coverage between 3D-CRT and IMRT. Although the SB volume irradiated high dose was significantly reduced with IMRT, low dose of it increased with IMRT. In aspect of small bowel sparing, IMRT can be used more effectively in upper rectal cancer. AuthorDisclosure:H. Lee:None. J. Kim:None. I. Cho:None. S. Park:None. S. Yoon: None. Y. Kim: None. S. Song: None. S. Lee: None. E. Choi: None. S. Ahn: None.

A New Laparoscopic Surgical Procedure to Achieve Sufficient Mesorectal Excision in Upper Rectal Cancer

Objective. Mesorectal excision corresponding to the location of a tumor, termed tumor-specific mesorectal excision (TSME), is commonly performed for resection of upper rectal cancer. We devised a new laparoscopic procedure for sufficient TSME with rectal transection followed by mesorectal excision. Operative Technique. After mobilization of the sigmoid colon and ligation of inferior mesenteric vessels, we dissected the mesorectum along the layer of the planned total mesorectal excision. The rectal wall was carefully separated from the mesorectum at the appropriate anal side from the tumor. After the rectum was isolated and transected using an endoscopic linear stapler, the rectal stump drew immediately toward the anal side, enabling the mesorectum to be identified clearly. In this way, sufficient TSME can be performed easily and accurately. This technique has been successfully conducted on 19 patients. Conclusion. This laparoscopic technique is a feasible and reliable procedure for achieving sufficient TSME.

How important is peritoneal involvement in rectal cancer? A prospective study of 331 cases

The importance of circumferential resection margin involvement in predicting locoregional recurrence and death from rectal cancer is well known. However, it is well accepted that cases of rectal carcinoma recur when this surgical margin is not compromised. The aim of this study was to analyse the influence of peritoneal involvement, among other clinicopathological variables, on locoregional recurrence and overall prognosis in an unselected prospective series of rectal cancer resections. This unselected prospective study assessed 331 rectal carcinoma cases from a colorectal cancer study that recruited more than 1000 cases. Meticulous pathological examination was performed by one pathologist, with particular attention paid to the peritoneal surface. All clinicopathological variables were entered into a database with comprehensive clinical follow-up. Peritoneal involvement was a significant factor in prognosis on univariate analysis but not on multivariate analysis. However, in analysing the causes of locoregional recurrence specifically, it may have been a factor in causing this in up to half the cases. This study adds to the small amount of literature data on the potential importance of peritoneal involvement in predicting locoregional recurrence and overall prognosis, especially in upper rectal cancer.

Laparoscopic low vs. high anterior resection for rectal cancer

In the October issue of Surgical Endoscopy, Kuroyanagi and colleagues evaluated laparoscopic low anterior resection for lower rectal cancer by double-stapling technique (DST). Current and emerging rapid technological advances allow biomedical research and applied sciences important progress in the development of new drugs and medical devices for improving outcomes of patients with solid cancer. In the field of translational research, modern molecular technology-based advances in genetics, genomics, and systems biology allow optimism for developing new markers and novel targeted drugs. This high-throughput technology has already resulted in excellent research findings, which are now incorporated in a large number of targeted agents, which are tested in preclinical and clinical trials [2–8]. In contrast to these future expectations, laparoscopic or robotic surgery can immediately improve short-term and long-term quality of life of patients with colorectal, gastric, and other solid tumors [9–13]. To test the safety efficacy of new drugs and medical devices, as minimally invasive techniques, the U.S. Food and Drug Administration (FDA) has established strict criteria for approval, ensuring a highquality public health. Comparative-effectiveness research (CER) is currently required for approval of new therapies in medical practice. However, whereas phase III, randomized, controlled trials are required for new drugs before these can become widely used, no CER data are required by the FDA for medical devices approval [14]. Therefore, careful evaluation of current data is required to assess the safety and efficacy of laparoscopic surgery in solid cancers. The best tool of CER—phase III trials and meta-analyses—has provided good-quality evidence for the safety and superiority of laparoscopic surgery over open resection, regarding short-term outcomes for colon cancer [15]. But particularly for low rectal cancer, evidence for the superiority of laparoscopic versus open surgery is still scarce. Kuroyanagi et al. provide useful information for this location of cancer in the lower rectum. The authors compared clinicopathological features and short-term results between two groups: 98 patients with upper rectal cancer located between 75 and 150 mm from the anal verge (group A), and 61 with lower rectal cancer located within 75 mm from the anal verge (group B). There was no difference in operating time, and intraoperative blood loss was similar in the two groups. No conversion in both groups was required. There was no perioperative death in either group. Anastomotic leak rate was similar in the two groups (2% in group A vs. 3.3% in group B; p = 0.638). The authors concluded that laparoscopic surgery is safe and feasible for lower rectal cancer in a very select group of patients. The study is limited by the small number of patients with lower rectal cancer, their selection, the absence of randomization, and the lack of follow-up data to assess its efficacy regarding locoregional recurrence and survival. All these limit its power. But the participation of very experienced surgeons with laparoscopic low anterior resection has resulted in the safety of the procedure with E. Hanisch (&) Department of Surgery, Asklepios Klinik Langen, Academic Teaching Hospital JWG University Frankfurt, 63225 Langen, Germany e-mail: E.Hanisch@Asklepios.com

Comparison of the erectile function in male patients with rectal cancer treated by preoperative radiotherapy followed by surgery and surgery alone

This study evaluates the erectile function of male patients treated by preoperative radiotherapy followed by surgery and surgery alone for locally advanced rectal cancer. A total of 112 men treated by total mesorectal excision with autonomic nerve preservation were included. Seventy-three patients were treated by preoperative radiotherapy followed by surgery (RTS group), and 39 were treated by surgery alone (surgery group). Patients filled out the five-item version of the international index of erectile function (IIEF-5) questionnaire at least 6 months after initial erectile function assessment. We analyzed the impact of age, surgery type, location, and size of tumor on erectile function. Total score was decreased significantly at follow-up compared to initial assessment in both RTS and surgery group (20.31 +/- 4.39 vs. 11.52 +/- 4.83, P = 0.012; 19.86 +/- 4.61 vs. 14.07 +/- 6.37, P = 0.031, respectively). Score difference was statistically higher in RTS group compared with surgery group (P = 0.028). In terms of surgery type for RTS group, score difference was statistically higher in the patients with abdominoperineal resection (APR) compared with those with lower anterior resection (P = 0.023). In comparison of score difference according to tumor location, difference was statistically higher in the patients with lower rectal cancer compared with those with upper rectal cancer (P = 0.017). The erectile functions of patients treated by preoperative radiotherapy followed by surgery are more affected than that of patients treated by surgery alone in locally advanced rectal cancer. Also APR and lower rectal cancer were significantly associated with erectile dysfunction in the patients treated by preoperative radiotherapy followed by surgery.

Lateral pelvic lymph-node dissection: still an option for cure

114 www.thelancet.com/oncology Vol 11 February 2010 We read with great interest the article “Extended lymphadenectomy versus conventional surgery for rectal cancer: a meta-analysis” by Georgiou and colleagues in The Lancet Oncology. However, we have to disagree with the methodology and conclusions. The title of the paper suggests that the authors did a meta-analysis and concluded that extended lymphadenectomy does not confer a signifi cant oncological advantage, and is associated with increased genito-urinary dysfunction, compared with conventional surgery. However, there are some fundamental problems with the methods used which result in some misleading conclusions. The main issue revolves around the validity of doing a meta-analysis on disparate groups. With the exception of the single small randomised study, the extended lymphadenectomy group undoubtedly had more advanced tumours—ie, larger (higher T stage), nodepositive, and more aggressive pathology—compared with the non-extended lymphadenectomy group. Therefore, one cannot “meta-analyse” these entirely diff erent groups. In fact we would interpret the results as the exact opposite to the authors’ conclusion: the extended lymphadenectomy group benefi ted substantially, as the survival and local recurrence were the same despite the more advanced nature of the disease. Furthermore, the time period of this review is very long (1984–2007). Over the past two decades, as Moriya argued in his article in the same issue of The Lancet Oncology, there have been substantial changes in the Japanese approach to treating rectal cancer in terms of indication criteria and the techniques used. Extended lymphadenectomy for upper rectal cancer has practically been abandoned, and Japanese surgeons are far more selective in the indications for extended lymphadenectomy using meticulous analysis of their experiences, and outcomes, and using modern imaging techniques. Additionally, nerve-sparing techniques have recently been developed and refi ned with markedly improved function. Based on a large recent multicentre study and other reports, we strongly believe that recent refi nements and optimal extended lymphadenectomy might be benefi cial to selected patients, particularly with low rectal cancer, and perhaps equivalent or better than pre-operative chemoradiotherapy and standard total mesorectal excision. The misinterpretation of the data in Lateral pelvic lymph-node dissection: still an option for cure

Patients With Low Rectal Cancer Treated by Abdominoperineal Excision Have Worse Tumors and Higher Involved Margin Rates Compared With Patients Treated by Anterior Resection

Patients with low rectal cancer have worse outcomes compared to those with upper rectal cancer. Reports suggest that low anterior resection may be oncologically superior to abdominoperineal excision, although no good evidence exists to support this. We looked at a recent series of patients with low rectal cancer to explore some of the issues. We analyzed 153 patients from the MERCURY study with low rectal cancer (<or=6 cm from the anal verge). The median tumor height, percentage undergoing neoadjuvant therapy, involved margin rates, and degree of local invasion were compared for abdominoperineal excision vs low anterior resection. The mean tumor height from the anal verge was 2.9 cm for the patients with abdominoperineal excision vs 4.6 cm in the patients with low anterior resection. The involved margin rate was 20% overall, but was 31.9% for abdominoperineal excision vs 12% for low anterior resection. More patients who had abdominoperineal excision had neoadjuvant therapy (64% vs 41%) and a higher proportion had more locally advanced (T4) tumors. Patients undergoing abdominoperineal excision have higher involved margin rates; however, they had lower and more locally extensive tumors despite a greater proportion undergoing neoadjuvant therapy. Patients with low rectal cancer pose difficulties with regard to optimal management. Targeted strategies are needed to improve outcome in this complex and common cancer.

Laparoscopic Resection for Rectal Cancers

The aim of this study is to evaluate the short-term outcomes and long-term survival of laparoscopic rectal cancer resection at a single institution with 579 cases over a 15-year period. The use of laparoscopic resection for colon cancer has been shown to be safe with comparable oncological outcomes. However, the role of laparoscopic resection for rectal cancer is still controversial with few studies looking into long-term outcomes. From May 1992 to April 2007, 579 patients underwent laparoscopic resection for rectosigmoid and rectal cancer. The clinical data of these patients were retrospectively reviewed from a prospectively collected database. Data evaluated includes short- and long-term results, with survival outcomes calculated using the Kaplan-Meier method. Over this 15-year period, 316 patients had laparoscopic anterior resection for rectosigmoid and upper rectal cancer, 152 patients had laparoscopic sphincter-saving total mesorectal excision, 92 patients had laparoscopic abdominoperineal resection, 17 patients had laparoscopic Hartmann procedure for rectal cancer, and 2 patients had proctocolectomy. The median age of these patients was 68 years (range, 35-95). The overall early and late operative morbidity was 18.8% and 9.7%, respectively. Conversion to open surgery was required in 5.4%of patients. Anastomotic leak rate was 3.5%. The median follow-up time was 56 months (range, 8-288). Port-site recurrence occurred in 2 patients. Locoregional recurrence occurred in 7.4% of patients after curative resection. The overall 5- and 10-year survivals for rectal cancer were 70% and 45.5%, respectively. The cancer-specific 5- and 10- year survival was 76% and 56%, respectively. The results of this study with large number of patients over a long follow-up period suggested that laparoscopic resection for rectal cancer is safe with good long-term oncological outcomes.

Different Patterns of Lymphatic Spread of Sigmoid, Rectosigmoid, and Rectal Cancers

We tried to evaluate the clinicopathological characteristics of rectosigmoid cancer compared with those of sigmoid and rectal cancer. We collected data on patients who underwent curative resections for sigmoid (399; SC group), rectosigmoid (175; RS group), and upper rectal cancer (453; RA group) between June 1996 and December 2007. The mean distance from the anal verge was 12.5 cm for rectosigmoid cancer, 13 cm for sigmoid cancer, and 9.8 cm for rectal cancer. The most common metastatic lymph nodes were pararectal nodes for the RS and RA groups and sigmoid mesenteric lymph nodes for the SC group. In a comparison of categories N2 and N1 for SC and RA groups, the increase of the metastasis rate was similar for all lymph nodes groups. However, for the RS group, the increase of metastasis to pararectal nodes was prominent in the N2 category. Overall recurrence and disease-free survival rate were not different among the groups. For stage III disease, the local recurrence rate was significantly higher in the RA group; the disease-free survival rate was higher in the SC group, and the RS group showed results similar to those of the RA group. Clinicopathological characteristics of rectosigmoid cancer were similar to those of sigmoid or rectal cancer. For lymphatic spreads, it was different from sigmoid or rectal cancer and more frequently metastasized to pararectal nodes. Oncologic results were slightly unfavorable to sigmoid colon, and showed data similar to those of rectal cancer. Therefore, rectosigmoid cancer was a "real" classification of colorectal cancer with unique lymphatic spread.

Results of a multicenter study of 1,057 cases of rectal cancer treated by laparoscopic surgery

The aim of this study was to clarify the feasibility of laparoscopic surgery for rectal cancer retrospectively in 28 centers throughout Japan. Between May 1994 and February 2006, 1,057 selected patients with rectal cancer underwent laparoscopic surgery. All the data regarding the patient details, and operative and postoperative outcome were collected retrospectively. Mean follow-up was 30 months. Procedures included anterior resection in 938, abdominoperineal resection in 107, Hartmann's procedure in 10, and others in two patients. Conversion to open procedures occurred in 77 patients (7.3%). Postoperative surgical complications developed in 235 patients (22.2%), including anastomotic leakage in 84 (9.1%). Median length of postoperative hospital stay was 15 days (7-271 days). Patients with upper rectal cancer had shorter hospital stay than those with lower rectal cancer (14 versus 18 days, p < 0.01). Tumor-node-metastases (TNM) stage included 83(7.9%) stage 0, 495 (46.8%) stage I, 197 (18.6%) stage II, 230 (21.8%) stage III, and 52 (4.9%) stage IV. Recurrence was developed in 67 patients (6.6%) of the 1,011 curatively treated patients. Local recurrence occurred in 11 patients (1.0%). There was no port-site metastasis. Of the 1,011 curatively treated patients, the 3-year disease-free survival rate was 100% in stage 0, 94.6% in stage I, 82.1% in stage II, and 79.7% in stage III. Laparoscopic surgery is feasible and safe in selected patients with rectal cancer, with favorable short-term and mid-term outcome.