Jeng Yi Wang

Value of carcinoembryonic antigen in the management of colorectal cancer

PURPOSE: The practical value of carcinoembryonic antigen (CEA) assay in the management of colorectal cancer after surgery is controversial. The value of CEA in the management of colorectal cancer was reviewed and discussed to justify the use of CEA assay in the management of colorectal cancer. METHODS: A retrospective study was performed on 318 patients who underwent resection by one surgeon (JYW) between 1981 and 1986 and who were followed for a minimum of 5 years or until death. RESULTS: The incidence of preoperative CEA levels >5 ng/ml in Dukes Stages A, B, C, and D were 0, 32, 48, and 79 percent, respectively. Five-year survival rates for groups with CEA levels ≤5 ng/ml and >5 ng/ml were 85 percent and 55 percent (P< 0.05), respectively, in Dukes Stage B patients and 64 percent and 37 percent (P< 0.05) in Stage C patients. The sensitivity and specificity of postoperative CEA monitoring in detecting recurrent diseases were 66 percent and 94 percent, respectively, for patients with a preoperative CEA value ≤5 ng/ml and 97 percent and 88 percent for patients with a higher preoperative CEA value. CONCLUSION: CEA is still the best tumor marker available to be used as an independent prognostic factor and as a monitor for recurrence of disease after primary tumor resection.

Resection of liver metastases from colorectal cancer: Are there any truly significant clinical prognosticators?

PURPOSE: This study was designed to evaluate the prognostic significance of various prognostic factors affecting recurrence after resection of colorectal hepatic metastases. PATIENTS AND METHODS: Records of 54 patients who had hepatic resection between 1986 and 1993 for metastatic liver tumor from colorectal cancer were reviewed. Factors analyzed were those reported to be of prognostic significance in other studies, including gender, primary tumor site, Dukes stage, diagnostic interval, grade, preoperative carcinoembryonic antigen (CEA) level, number of metastases, size of metastases, distribution of metastases, type of resection, resection margin, and estimated blood loss. RESULTS: Average follow-up of surviving patients was 28 (range, 12–89) months. Average survival time from date of hepatic resection was 26 months, with an estimated actuarial survival rate of 25.5 percent at five years. Using the multivariate analysis of factors, gender and preoperative CEA level were shown to be significantly related to overall survival (P=0.0455 and 0.054, respectively). Cancer of the right side colon had significant correlation with hepatic “recurrence” (P=0.0071). CONCLUSIONS: Female patients and those with preoperative CEA values higher than 20 ng/ml have a better chance of survival following hepatic resection. Cancer of the right colon has a greater tendency for hepatic recurrence than that of the left colon.

The role of lasers in hemorrhoidectomy

Eighty-eight patients who received treatment for hemorrhoids were randomized into two groups. Group A received the Nd-YAG laser phototherapy for internal hemorrhoid combined with the CO2 laser for external hemorrhoid. Group B was treated with closed Ferguson hemorrhoidectomy. The need of narcotic injections for pain relief was 11 percent in group Avs.56 percent in group B (P<0.001). The incidence of postoperative urinary retention was 7 percent in group A,vs.39 percent in group B (P<0.05). No enema was required postoperatively in group A,vs. 9 percent in group B; 84 percent of the patients in group A were discharged on the second postoperative day,vs. 83 percent of the patients in group B discharged on the fifth postoperative day. The cost was 20 percent less in the former group. The overall complications in both groups were insignificant in difference, except prolonged wound healing in group A was noted. One year follow-up showed satisfactory results. Laser treatment is considered one of the alternatives to conventional treatment, but the surgeon needs to be aware of laser hazards.

Pelvic peritoneal reconstruction to prevent radiation enteritis in rectal carcinoma

Some patients with rectal cancer who undergo exenterative surgery may require radiation therapy as an adjuvant treatment for recurrent or residual disease. A common devastating side effect of this treatment modality is radiation enteritis, a radiation-induced small bowel injury. Hence, the prevention of such a complication is essential for both the surgeon and the radiation oncologist. A new surgical method using the posterior rectus sheath and peritoneum to partition the abdominal cavity at the level of the umbilicus to the sacral promontory seems to accomplish this purpose, keeping the small bowel away from the pelvic cavity. After removal of the rectal lesion [eight abdominoperineal resections (APRs), nine Hartmanns procedures, and one low anterior resection (LAR)] in 18 patients with rectal cancer, this new surgical procedure was performed. One of the patients had an early postoperative intestinal obstruction, and all but one of the patients received postoperative adjuvant radiation therapy. In addition, a small bowel series was performed before the radiation therapy and six months and one year after surgery. Upon examination, most of these patients still had their small bowel kept intact in the abdominal cavity. During the follow-up period of 10 months to 2 years with an average of 18 months, two late complications of intestinal obstruction were noted. Exploratory laparotomy of these two patients revealed radiation enteritis of the small bowel. Therefore, the failure rate of the following procedure is 12 percent, since 2 of the 17 patients received small bowel injury. Although the follow-up period for this surgical method is short, the results have encouraged us to continue the use of this procedure on advanced rectal cancer patients who require postoperative radiation therapy.

Perforated rectal lymphoma in a renal transplant recipient

PURPOSE: We report the case of a renal transplant recipient with rectal lymphoma manifested by sudden onset of abdominal pain from a perforated rectum who was treated successfully with prompt surgical resection and reduction of immunosuppressants. METHODS: An emergent anterior resection with Hartmanns procedure was done. Immunosuppressants were drastically reduced by discontinuation of cyclosporine. RESULTS: Pathologic examination showed diffusely infiltrated large-cell malignant lymphoma with an immunoblastic feature. The patient has been followed-up for four years, with no tumor recurrence or graft rejection. CONCLUSION: Rectal lymphoma, although rare, should be kept in the list of differential diagnoses for transplant recipients who exhibit lower gastrointestinal bleeding, intestinal obstruction, or abdominal pain.

Pathogenetic implications of DNA nondiploidy in colorectal cancers.

PURPOSE: Several studies propose that proximal and distal colorectal cancers have a different pathogenesis. We tested the hypothesis using flow cytometric DNA analysis. METHODS: DNA analysis was performed in 719 patients with colorectal cancer. In addition, histopathologic data were re-evaluated in a blinded fashion by a single pathologist. RESULTS: Distal tumors were more often nondiploid than were proximal tumors (61vs.49 percent;P=0.015). Compared with the proximal tumor, distal tumors were smaller (P=0.0001) and had less desmoplastic reaction (39vs.53 percent;P=0.0001). Tumor location had no significant associations with the remaining parameters, including mucin production, perineural invasion, blood/lymphatic vessel invasion, lymphocytic infiltration, histologic grade, tumor stage, gross appearance, age, and gender. CONCLUSIONS: The unequal distribution of ploidy suggests distinct pathogenetic mechanisms at proximal and distal sites.

Status for clinically complete remission rectal cancer after concomitant chemo-radiotherapy in Taiwan

Treatment for Rectal cancer changed after the induction of concomitant chemo-radiotherapy, CCRT. Complete remission of the tumor leads to debate of the necessity of surgical intervention. We evaluate the treatment outcome to know if operation is beneficial to these patients. Patients received long course concomitant chemo-radiotherapy for advanced rectal cancer between 2004 and 2013 in Taiwan were enrolled. Total 2780 patients diagnosed advanced rectal cancer were enrolled. In these patients, 2578 received surgical intervention and 202 were in wait and see for complete remission tumor. Higher local recurrence rate was found with wait and see group (8.9% vs. 2.7%). Also, better overall survival, disease free survival and local recurrence free survival were seen with the surgical intervention group. Surgical intervention may be benefit for some misdiagnosed completed response to CCRT.