Chung-Rong Changchien

The oncologic benefit of high ligation of the inferior mesenteric artery in the surgical treatment of rectal or sigmoid colon cancer

PurposeIt remains controversial as to whether high ligation of the inferior mesenteric artery (IMA) should be performed during surgical treatment for sigmoid colon or rectal cancer. The purpose of this study is to attempt to clarify the extent of the oncologic benefit of high ligation of the IMA.Materials and methodsFrom January 1995 to July 2001, a total of 1,389 patients underwent high ligation of the IMA; 387 patients featured non-disseminated sigmoid colon cancer and 1,002 patients had rectal cancer. Pathology of the primary tumors, IMA nodes, and clinical outcome were reviewed.ResultsForty-three patients (3.1%) revealed IMA node metastasis. Of these 43 patients, 29 (67.4%) featured tumor recurrences/metastases. After a minimum 5-year follow-up, 11 of these 43 patients (25.6%) were alive and disease free. Of these 43 patients, the 5-year disease-free survival rate for patients featuring sigmoid cancer was 50% and for patients with rectal cancer 13.8%. The beneficial rate of high ligation of the IMA for non-disseminated sigmoid colon cancer and rectal cancer was 0.8%, for non-disseminated sigmoid colon cancer 1.8%, and for non-disseminated rectal cancer, the rate was only 0.4%. The rates of IMA metastasis in patients with T stage tumors were 0% (pT1), 1.0% (pT2), 2.6% (pT3), and 4.3% (pT4).ConclusionsAlthough patients afflicted with IMA node metastasis revealed a rather high incidence of tumor recurrence/metastasis, 25.6% of these patients remained disease free following IMA node dissection after a minimum 5-year follow-up. We consider that IMA node dissection is more beneficial in patients with non-disseminated sigmoid pT4 tumor.

Solitary rectal ulcer syndrome : An endoscopic and histological presentation and literature review

BackgroundAlthough the clinicopathologic features of solitary rectal ulcer syndrome (SRUS) are well documented, the heterogeneous endoscopic appearance of lesions that the syndrome produces and its rare incidence may make for clinical confusion.MethodsTogether with a literature review, we describe the variety of lesions experienced in our hospital with a series of endoscopic and histological illustrations and emphasize the diagnostic dilemma both clinically and histologically.ConclusionsWith comparison of different macroscopic presentations of SRUS, more correct diagnoses will be achieved and more successful treatments will be reported.

Utility of 2-fluoro-2-deoxy-D-glucose positron emission tomography in managing patients of colorectal cancer with unexplained carcinoembryonic antigen elevation at different levels.

PURPOSESerum carcinoembryonic antigen elevation without detectable relapse during colorectal cancer follow-up presents a challenge. This study was designed to evaluate the utility of fluorine-18-labeled 2-fluoro-2-deoxy-D-glucose positron emission tomography in colorectal cancer patients with unexplained carcinoembryonic antigen elevation at different levels.METHODSThirty-seven colorectal cancer patients referred for positron emission tomography after primary surgery who had serum carcinoembryonic antigen levels >5 ng/ml and negative or equivocal conventional imaging studies were analyzed. Patient status was determined by histopathology and/or clinical follow-up. Grouping as disease-free, potentially resectable, or advanced disease was performed. The management impact was defined as the percentage of patients with a true-positive positron emission tomography result.RESULTSThe sensitivity, specificity, and accuracy of positron emission tomography for relapse detection were 89, 89, and 89 percent, respectively. The management impact was 68 percent. In 24 patients with carcinoembryonic antigen levels <25 ng/ml, positron emission tomography helped correct patient grouping in 20 patients (83 percent), including 8 in the disease-free group, 5 in the potentially resectable group, and 7 in the advanced-disease group. In 13 patients with carcinoembryonic antigen levels >25 ng/ml, positron emission tomography identified 8 patients in the advanced-disease group and 1 patient in the potentially resectable group but missed 2 patients with relapse and undergrouped 2 patients in the advanced-disease group as potentially resectable.CONCLUSIONS2-fluoro-2-deoxy-D-glucose positron emission tomography can help triage patients for appropriate management with unexplained carcinoembryonic antigen elevation <25 ng/ml. For patients with unexplained elevation of carcinoembryonic antigen >25 ng/ml, the utility of positron emission tomography is mainly to confirm the presence of advanced disease and occasionally to identify potentially resectable lesions.

Pathological examination of 12 regional lymph nodes and long-term survival in stages I–III colon cancer patients: an analysis of 2,056 consecutive patients in two branches of same institution

PurposePathologic examination of at least 12 lymph nodes (LNs) is widely accepted as a standard for colon cancer surgery. We sought to address its association with patient source, other clinicopathological factors, and survival by comparing information from two branches in a large single institution.MethodsPatients with stages I–III adenocarcinoma of the colon between 1998 and 2003 were identified from the Chang Gung Colorectal Tumor Registry in two branches (Linkou and Kaohsiung branches) of same institution. We used multivariate analysis to adjust for variables with P < 0.1 in univariate analyses.ResultsA minimum of 12 examined nodes were observed in 80% of patients in Linkou branch versus 25% in Kaohsiung branch (P < 0.0001). Younger age, right hemicolectomy, larger tumor, higher tumor stage, higher caseload of surgeons, and patients at Linkou branch with an odds ratio (OR) as high as 23 (95% CI, 17–31) were independently associated with a higher frequency of ≥12 examined nodes. Patients with examined node number of <12 had a greater risk of recurrence within stages II and III (stage II: adjusted OR 1.88, 95% CI 1.27–2.79; stage III: adjusted OR 1.58, 95% CI 1.15–2.17) but not within stage I (OR 0.73, 95% CI 0.23–2.24).ConclusionsThe results confirm that factors influencing nodal harvest are multifactorial and the examined LN number of 12 or more is associated with an increased long-term survival in stages II–III colon cancer. It is possible to adequately sample and examine a sufficient number of nodes in the majority of colon cancer specimens by standardized conventional methods.

Role of body mass index in colon cancer patients in Taiwan

AIM To determine the effect of body mass index (BMI) on the characteristics and overall outcome of colon cancer in Taiwan. METHODS From January 1995 to July 2003, 2138 patients with colon cancer were enrolled in this study. BMI categories (in kg/m²) were established according to the classification of the Department of Health of Taiwan. Postoperative morbidities and mortality, and survival analysis including overall survival (OS), disease-free survival (DFS), and cancer-specific survival (CSS) were compared across the BMI categories. RESULTS There were 164 (7.7%) underweight (BMI < 18.5 kg/m²), 1109 (51.9%) normal-weight (BMI = 18.5-23.9 kg/m²), 550 (25.7%) overweight (BMI = 24.0-26.9 kg/m²), and 315 (14.7%) obese (BMI ≥ 27 kg/m²) patients. Being female, apparently anemic, hypoalbuminemic, and having body weight loss was more likely among underweight patients than among the other patients (P < 0.001). Underweight patients had higher mortality rate (P = 0.007) and lower OS (P < 0.001) and DFS (P = 0.002) than the other patients. OS and DFS did not differ significantly between normal-weight, overweight, and obese patients, while CSS did not differ significantly with the BMI category. CONCLUSION In Taiwan, BMI does not significantly affect colon-CSS. Underweight patients had a higher rate of surgical mortality and a worse OS and DFS than the other patients. Obesity does not predict a worse survival.

Oxaliplatin with Weekly Bolus 5-Fluorouracil and Leucovorin in Pretreated Advanced Colorectal Cancer Patients: A Phase II Study

Background: The purpose of this study was to determine the efficacy and toxicity of oxaliplatin in combination with weekly bolus 5-fluorouracil (5-FU) and leucovorin (LV) in patients with 5-FU-pretreated advanced colorectal cancer. Methods: A total of 39 patients with documented 5-FU-resistant advanced colorectal cancer were enrolled. All 39 patients had previously received weekly high-dose 5-FU/LV (2,600 mg/m2 5-FU plus 100 mg/m2 LV as 24-hour infusion) as first-line chemotherapy for metastatic disease. Oxaliplatin (85 mg/m2) was delivered as an intravenous infusion over 2 h on days 1 and 15, while 5-FU (500 mg/m2) and LV (20 mg/m2) were administered as an intravenous bolus on days 1, 8 and 15. One treatment course consisted of 3 consecutive weeks of therapy followed by a 1-week rest. Results: In an intent-to-treat analysis, the objective response rate for the 39 patients was 20.5% (95% confidence interval, 7.2–33.8%). The disease was stable in 19 patients (48.7%), and progressive in 11 (28.2%). The median survival for all 39 patients was 8.9 months. The median time to progression was 5.0 months. Grade 3/4 neutropenia occurred in only 1 patient (2.6%), and grade 2 and 3/4 peripheral neuropathy occurred in 10 (25.6%) and 5 (12.8%) patients, respectively. Conclusion: Oxaliplatin in combination with weekly bolus 5-FU/LV is also active in patients with advanced colorectal cancer where first-line treatment has failed.

Carcinoma obstruction of the proximal colon cancer and long-term prognosis—obstruction is a predictor of worse outcome in TNM stage II tumor

PurposeColon obstruction is suggested to be a predictor of poor outcome in colon cancer. However, the effect of obstruction on outcome in patients with different tumor–nodes–metastases (TNM) stage cancer has not been fully addressed. The aim of this study is to determine whether colon obstruction predicts surgical and long-term oncologic outcomes in patients with proximal colon cancer.MethodsA total of 1,492 consecutive patients underwent open resection of primary adenocarcinoma of right colon in a single institution between January 1995 and December 2005. Clinical and follow-up data were extracted from a prospective colorectal cancer database. Univariate and multivariate analyses were performed to identify colon obstruction and other predictors of surgical and oncologic outcomes.ResultsAmong 1,492 patients, 306 (20.5%) patients presented with colon obstruction. The rates of surgical morbidity and mortality were greater in patients with an obstruction as compared to patients without an obstruction (22.2% and 3.9% vs. 14.1% and 1.9%; p = 0.0005 and 0.041, respectively). Obstruction predicted a worse long-term disease-free survival (DFS) among patients with stage II–III disease (log-rank test, p = 0.0003). The data were stratified by TNM stage. Obstruction predicted a worse DFS among patients with TNM stage II cancer (598 patients; log-rank test, p = 0.001; Cox regression, p = 0.012), but it was not a predictor in TNM stage III cancer patients (424 patients; p = 0.116; p = 0.108).ConclusionsColon obstruction was an independent predictor of long-term outcome only in TNM stage II but not in stage III proximal colon cancer. Patients with TNM stage II obstructive colon cancer could be included in future trials of adjuvant therapies.

Massive hematochezia from acute hemorrhagic rectal ulcer in patients with severe comorbid illness: rapid control of bleeding by per anal suturing of bleeder using anoretractor.

PurposeMassive hematochezia from acute hemorrhagic rectal ulcer can arise in patients with severe comorbid illness who are bedridden for long periods. If the bleeder is not found and treated immediately, the bleeding will cause deterioration of health and even threaten life. The results of the current study show how quickly and safely per anal suturing can treat acute hemorrhagic rectal ulcer.MethodsFrom January 2003 to December 2003, the records of 26 patients who underwent per anal suturing of acute hemorrhagic rectal ulcer were retrospectively reviewed. The identification of acute hemorrhagic rectal ulcer was confirmed by clinical and anoscopic examination.ResultsMost of these patients were elderly and bedridden (14 men; median age 69 years). Main comorbid illnesses existed in all patients and included liver cirrhosis (8 patients, 31 percent), sepsis (13 patients, 50 percent), cerebral vascular accident (15 patients, 58 percent), respiratory failure (13 patients, 50 percent), and malignancy (7 patients, 27 percent). Effective hemostasis was achieved in all patients by direct suture of bleeding ulcer. No complications developed relative to the per anal suturing procedure among any patients. Although 11 patients developed recurrent hematochezia, 9 patients responded to repeated therapy. The risk factors associated with recurrent bleeding were severity of disease and abnormal coagulation.ConclusionsWhen massive hematochezia occurs in bedridden patients with severe comorbid illness, it is essential to investigate the lower rectum, which often is affected by acute hemorrhagic rectal ulcer. Recognition of this clinical presentation will result in early identification and therapy. Per anal suturing of a bleeder at the bedside provides a quick, safe, and successful management of acute hemorrhagic rectal ulcer.

Neuroendocrine Carcinomas of the Colon and Rectum: Result of a 15-year Experience

Purpose. The experience of the uncommon malignancy, neuroendocrine carcinomas of the colon and rectum with emphasis on the pathology and clinical characteristics at a single hospital was reviewed. Methods. Of more than 11,000 colon or rectal cancers removed from July 1992 to June 2007 at Chang Gung Medical Center in Taipei, 11 cases diagnosed as colon or rectal neuroendocrine carcinoma were evaluated. Pathology was reviewed by a single pathologist. Medical records were retrospectively reviewed and patients were analyzed in terms of clinicopathologic and demographic characteristics including neuroendocrine type, tumor location, tumor stage, responses to treatment (operative procedure, chemotherapy or radiotherapy), metastases, and survival. Results. Five patients had distant metastasis at the time of diagnosis. Palliative chemotherapy or radiotherapy did not seem to offer a modest improvement in survival for these patients, with an overall survival of less than 11 months after diagnosis. Lymph node metastasis was found in 75%, and the distant metastasis in 45% of the 11 patients at the time of diagnosis. Overall survival rates for six-month, one-year, and three-year survival were 73 percent, 45 percent, 20 percent, respectively. These findings are in accordance with other publications, which demonstrate that the neuroendocrine carcinomas behave aggressively and are associated with worse prognosis than that of conventional adenocarcinomas of the same stage. Unexpectedly, improved results were found for two stage IIA and IIIB rectal small cell neuroendocrine carcinoma patients administered with adjuvant chemotherapy treatment with cisplatin and etoposide at our hospital. They were alive without evidence of disease at more than 10 years after treatment. Conclusions. Neuroendocrine malignancies are rare but behave aggressively in the colon or rectum, accounting for less than 0.1 percent of all colorectal cancers at our institution. Aggressive adjuvant chemotherapy with cisplatin and etoposide might offer a better chance of long-term survival for patients with stage Ⅱ and Ⅲ neuroendocrine carcinomas in the colon and rectum, which deserves further investigation.

Postoperative adjuvant radiotherapy in Astler-Coller stages B2 and C rectal cancer

Between 1979 and 1983, 127 patients with Stages B2 or C rectal cancer treated with surgery plus postoperative adjuvant radiotherapy (RT group) and 122 patients treated with surgery alone (S group) were compared to evaluate the effect of postoperative radiotherapy on survival and disease recurrence. Each group was stratified into subgroups according to stage and tumor differentiation as follows: Subgroups BW (Stage B2 and well-differentiated tumor), BM (Stage B2 and moderately differentiated tumor), CW (Stage C and well-differentiated tumor), CM (Stage C and moderately differentiated tumor), and P (poorly differentiated tumor). Ninety-five percent of the patients were followed until death or, if alive, to five years after surgery. Postoperative radiotherapy was associated with a reduced five-year survival rate in Subgroup BW (67vs.87 percent;P=0.02). In the remaining subgroups of the RT group, there was a statistically insignificant trend toward a worse survival rate (56vs.65 percent, 47vs. 64percent, 41vs.46 percent, and 50vs.36 percent for Subgroups BM, CW, CM, and P, respectively). The local failure rates for the S group and RT group were 10vs.23 percent (P=0.15) in Subgroup BW, 32vs.21 percent (P=0.4) in Subgroup BM, 24vs.25 percent (P=0.6) in Subgroup CW, and 18vs.18 percent (P=0.6) in Subgroup CM, respectively. Eight percent (9/127) had severe or life-threatening radiation-related complications. Postoperative adjuvant radiotherapy alone did not improve the survival of patients with Stages B2 or C rectal cancers. It may have led to worsened survival in the subgroup of patients with well-differentiated Stage B2 rectal cancer.