Mario Benati

Simultaneous colorectal and hepatic resections for colorectal cancer: postoperative and longterm outcomes

BACKGROUND Our goal was to analyze the results of resection of colorectal cancer and liver metastases in one procedure. STUDY DESIGN Between June 1982 and July 1998, 522 patients underwent liver resection for colorectal metastases. Liver resection was performed simultaneously with colorectal resection in 71 cases, representing the population in this study. Morbidity, mortality, overall survival, and disease-free survival times were analyzed. Median followup time was 29 months (range 6 to 162 months). Prognostic factors and their influence on outcomes were analyzed. RESULTS The median hospital stay was 8 days (range 5 to 23 days). Morbidity was 21% and included nine pleural effusions, seven wound abscesses, four instances of hepatic failure, three systemic infections, three intraabdominal abscesses, and one colonic anastomosis leakage. Operative mortality was 0%. Recurrence rate was 57.7% (41 or 71), and progression of disease was detected in 33.8%. Overall and disease-free survivals at 1, 3, and 5 years were 88%, 45%, and 38% and 67%, 17%, and 9%, respectively. Prognostic factors with notable influence on patient outcomes were nodal stage as per TNM classification, number of liver metastases, diameter (smaller or larger than 5 cm), liver resection specimen weight (lighter or heavier than 90 g), and liver resection margin (smaller or larger than 1 cm). CONCLUSIONS Simultaneous resection of colorectal cancer and liver metastases can be performed with low morbidity and mortality rates, avoiding a second surgical procedure.

Rectal cancer: local recurrence after surgery without radiotherapy.

PURPOSE: This study was designed to assess the local recurrence rate and prognostic factors for local recurrence in patients undergoing curative anterior or abdominoperineal resections without radiotherapy. METHODS: From January 1980 to December 1996, 514 consecutive patients underwent curative resections for rectal cancer. We excluded those with preoperative radiotherapy (n=23), postoperative radiotherapy (n=27), local resection (n=36), and 11 (2.1 percent) patients who died postoperatively. The remaining 417 patients (249 males) with a median age of 64 (range, 21–90) years were analyzed. For upper third lesions, mesorectal tissue was excised down to at least 5 cm below the tumor. Total mesorectal excision was performed for lower and middle tumors. Postoperative chemotherapy was limited to patients with Stage III lesions. Median follow-up (and 95 percent confidence interval) was (5.2 4.3–5.9) years, with 87.7 percent of patients followed up longer than 24 months. Local recurrence was defined as any recurrence within the field of resection, regardless of the presence or absence of distant metastasis. RESULTS: Five-year local recurrence rate(and 95 percent confidence interval) was 9.7 (6.4–13) percent, with a median time to diagnosis of 15 (10–23) months. Local recurrence rates in Stages I, II, and III were: 3.1, 4.1, and 24.1 percent, respectively (P < 0.0001). In relation to node status, local recurrence rates were N0, 4.1 (1.7–6.5) percent; N1, 12.6 (4.6–20.6) percent; N2, 32.1 (12.1–52.1) percent; and N3, 59.3 (22.5–96.1) percent; (P < 0.00001). Lower third tumors had a higher local recurrence rate than middle and upper third tumors: 17.9, 7.1, and 5.1 percent, respectively (P=0.002). Adjusted by stage, this difference was maintained only in Stage III tumors. Among lower tumors, those at 6 and 7 cm from the anal verge had a lower local recurrence rate than those below 6 cm (6.7vs. 26.2 percent, respectively;P=0.02). Accidental rectal perforation at or near the tumor site occurred in 12 cases (2.9 percent), showing a strong correlation with local recurrence (P < 0.0001). Multivariate analysis showed significant higher risk for lower third tumors (hazard ratio, 2.98) and positive nodes (hazard ratio, 4.78). CONCLUSIONS: Appropriate surgery without irradiation achieves excellent local control in N0 rectal cancers. Node metastasis, lower third localization (especially below 6 cm), and accidental rectal perforation at or near the tumor site are significantly associated with a higher local recurrence rate.

Lymph Node Ratio as Prognosis Factor for Colon Cancer Treated by Colorectal Surgeons

PURPOSE: This study was designed to assess the prognostic value of the lymph node ratio in patients with colon cancer treated by colorectal specialists. METHODS: Three hundred and sixty-two Stage III consecutive cases were analyzed based on quartiles: lymph node ratio 1 (>0 and <0.06); lymph node ratio 2 (between 0.06 and 0.12); lymph node ratio 3 (>0.12 and <0.25); lymph node ratio 4 (≥0.25). RESULTS: Disease-free survival rates were: lymph node ratio 1, 75.5%; lymph node ratio 2, 74.2%; lymph node ratio 3, 73.2%; and lymph node ratio 4, 40.1%. Similar differences were observed for cancer-specific and overall survival rates. Cases with lymph node ratio ≥0.25 had higher hazard ratios than cases with lymph node ratio <0.25 in terms of disease-free survival (2.8, P < 0.001), cancer-specific survival (3.1, P = 0.0001), and overall survival (2.2, P = 0.0001). The hazard ratio of cases with up to three positive nodes and lymph node ratios ≥0.25 was higher than that of cases with up to three positive nodes and lymph node ratios <0.25 in terms of disease-free survival (3.1, P = 0.003), cancer-specific survival (3.5, P = 0.002), and overall survival (2.4, P = 0.02). Similar differences were found for cases with more than three positive nodes. Lymph node ratio, but not number of positive nodes, had independent prognostic value in multivariate analysis. No interaction between these two variables was found. CONCLUSION: A lymph node ratio ≥0.25 was an independent prognostic factor in Stage III colon adenocarcinoma regardless of the number positive nodes. It modified outcomes predicted by the current staging system.

Colorectal Cancer Staging: Reappraisal of N/PN Classification

PURPOSE: Current American Joint Committee on Cancer and the Union Internationale Contre le Cancer TNM classification disregards location of positive nodes, discontinuing N3 category, which constitutes a major modification to 1987 version. This study was designed to assess the impact of the recategorization of former N3 cases and the reliability of the current N1-N2 subcategorization of Stage III patients. METHODS: Prospectively collected data from 1,391 patients (55.8 percent males; median age, 64 (range, 21–97) years), operated on with curative intent between 1980 and 1999, were analyzed. The median follow-up was 60 (interquartile range, 27–97) months with 129 cases lost to follow-up. RESULTS: Of positive node cases, 25.3 percent were former N3. Among them, 30.5 percent migrated to the N1 group and 69.5 percent to the N2 group. The proportions of former N3 cases in N1 and N2 groups were 12.5 percent and 46.1 percent, respectively (P < 0.001). Node-positive patients had an actuarial five-year survival rate of 56.7 percent (95 percent confidence interval, 53–59), with a significant difference between N1/N2 categories (63.6 vs. 44.1 percent, respectively; P < 0.001). Although apical node involvement and more than three positive nodes were associated with poorer outcomes in univariate analysis, only the number of positive nodes had independent association (hazard ratio, 1.6 (range, 1.2–2.2); P < 0.001). Integration of former N3 cases did not modify outcomes. CONCLUSIONS: The recategorization of former N3 involved a high proportion of positive node cases. Current N1/N2 categories clearly defined different outcomes and were not modified by the integration of former N3.