Michel Huguier

Duodénopancréatectomie céphalique pour cancer

Duodenopancreatectomie cephalique pour cancer M. Huguier, A. Barrier, C. Gouillat, B. Suc, D. Jaeck, B. Launois De nombreuses propositions ont ete faites pour ameliorer les resultats de l’operation de Whipple. Des etudes prospectives controlees (essais), des meta-analyses ou, a defaut, des etudes retrospectives permettent d’evaluer ces propositions. Les pancreatectomies totales et les curages cellulo-lymphatiques etendus ne semblent pas ameliorer les durees de survie des malades dans des comparaisons retrospectives ou dans des essais. Un envahissement veineux apparent, mesenterique superieur ou portal, ne contre-indique pas a lui seul une exerese dont les resultats sont similaires a ceux observes lorsqu’il n’existe pas d’envahissement. Des essais et une meta-analyse n’ont montre ni avantages ni inconvenients majeurs a la conservation antro-pylorique. Trois essais et une meta-analyse n’ont pas montre que l’anastomose pancreatico-gastrique diminuait le risque de fistule par rapport a l’anastomose pancreatico-jejunale. Deux essais suggerent que, pour la realisation de celle-ci, l’intubation du pancreas dans le jejunum ou le drainage externe temporaire du canal de Wirsung diminuraient ce risque de fistule ce qui, pour cette seconde technique, n’a pas ete confirme par un autre essai. Les resultats sur l’utilisation de la somatostatine sont contradictoires. Les resultats benefiques lorsque le critere de jugement de fistule est biologique n’ont pas ete confirmes par quatre essais sur cinq lorsque le critere de fistule etait clinique et/ou radiologique. Enfin, l’occlusion des canaux pancreatiques par de la fibrine ou l’utilisation de colle sur la surface de l’anastomose pancreatico-digestive n’ont pas diminue le risque de fistule. En conclusion, la duodeno-pancreatectomie cephalique decrite par Whipple reste la technique de reference d’exerese des cancers de la tete du pancreas. L’essai montrant l’interet de l’intubation du pancreas dans le jejunum merite d’etre confirme. En l’absence de resultats convergents, la somatostatine ou le drainage externe du canal de Wirsung peuvent etre reserves aux cas pour lesquels l’anastomose pancreatique semble precaire. Enfin, il a ete suggere par plusieurs etudes que l’experience des equipes semblait le meilleur moyen, non seulement de diminuer la morbidite et la mortalite peri-operatoires, mais aussi d’augmenter les chances de survie des malades.

Rectal cancer surgery in patients more than 80 years of age

BACKGROUND This retrospective study aimed to compare the prognosis for rectal cancer in patients more than 80 years old with that observed in younger patients. METHODS Patients operated on for a rectal adenocarcinoma, from 1980 to 1998, were divided into two groups: group 1 (>80 years, n = 92); group 2 (<80 years, n = 276). RESULTS There were significant differences between the two groups with regard to the sex ratio, the American Society of Anesthesiologists (ASA) classification, the emergency presentation, and the curative operation rate. The operative mortality rate was 8% in group 1, 4% in group 2 (P = 0.26). The overall 5-year survival rate was 35% in group 1, 53% in group 2 (P = 0.0004). In patients operated on for cure, the cancer-specific 5-year survival rate was 50% in group 1, 59% in group 2 (P = 0.08). CONCLUSIONS The prognosis for rectal cancer in patients over 80 years is not significantly different from that of younger patients. Surgery should not be restricted on the basis of age.

COMBINED RADIOTHERAPY AND CHEMOTHERAPY (CISPLATIN AND 5-FLUOROURACIL) AS PALLIATIVE TREATMENT FOR LOCALIZED UNRESECTABLE OR ADJUVANT TREATMENT FOR RESECTED PANCREATIC ADENOCARCINOMA: RESULTS OF A FEASIBILITY STUDY

PURPOSE To evaluate a cisplatin-containing chemoradiotherapy (CRT) regimen followed by chemotherapy for unresectable (locally advanced group, n = 32) and resected (adjuvant group, n = 10) pancreatic adenocarcinoma. The quality of palliation and percentage of secondary resections were also studied for unresectable disease. METHODS AND MATERIALS The protocol comprised CRT (45 Gy over 5 weeks), combined with 5-fluorouracil and cisplatin during the first and fifth weeks, followed, 3 weeks later, by 4 cycles of the same chemotherapy plus leucovorin. RESULTS All patients completed CRT but only 50% of each group finished the entire protocol. Gastrointestinal toxicity and weight loss were the major side effects during CRT. Enhanced hematological toxicity limited the post-CRT chemotherapy. For the locally advanced group, median survival was 9 months; 1- and 2-year survival rates were 31 and 12. 5%, respectively. The overall response rate was 16% and 50% had stable disease. A lasting palliative effect defined as improved performance status and decreased analgesic consumption, was recorded for 43% of the patients. Only three secondary resections have been performed. For the adjuvant group, median survival was 17 months. CONCLUSIONS Although toxic in advanced disease, this regimen significantly lowered pain and analgesic consumption, but had poor impact on secondary resectability. In an adjuvant setting, although equally toxic, this series was too small to allow conclusions to be drawn.

Treatment of Local Recurrence of Rectal Cancer

BACKGROUND Treatment of local recurrence of rectal cancer remains a challenge. Preoperative irradiation and total mesorectal excision halve the risks of local failure, but increase morbidity and even mortality. The results of re-resection of recurrent rectal cancer suggest need to reexamine therapeutic strategies for initial treatment. METHODS Seventy-one patients operated on for rectal carcinoma without radiotherapy developed local recurrence (29 with metastatic disease). Thirty underwent a curative re-resection (8 had combined resection of metastases). RESULTS The incidence of asymptomatic recurrence was higher after anterior resection (38%) than after abdominoperineal resection (16%). The actuarial 5-year survival rate was 19%; 28% in asymptomatic patients and 8% in symptomatic (P = 0.04). CONCLUSIONS Early detection of recurrence of rectal cancer leads to an improved re-resection rate and survival. In patients who did not undergo radiotherapy at the time of the original resection, re-resection can be achieved safely. The place for radiation in the treatment of rectal cancer must be redefined.

5‐Fluorouracil and cisplatin as palliative treatment of advanced oesophageal squamous cell carcinoma

OBJECTIVE To compare chemotherapy with no chemotherapy as palliative treatment for oesophageal squamous cell carcinoma. DESIGN Randomised study. SETTING Multicentre trial in France. SUBJECTS Of 161 patients with histologically confirmed oesophageal squamous cell carcinoma located more than 5 cm from the mouth of the oesophagus, five were withdrawn because of protocol violation. The remaining 156 patients, 149 men and 7 women, mean (SD) age 58 (9) years range 36 to 77, were randomly allocated to either a control group without chemotherapy (n = 84) or a group treated by chemotherapy (n = 72). Patients were divided into four strata: I = complete resection of the tumour but with lymph node involvement (n = 62); II = incomplete resection of tumour leaving gross tumour behind (n = 58); III = no resection because of local or regional invasion (n = 22) ; and IV = no resection because of distant metastasis (n = 14). Exclusion criteria were histologically confirmed tracheobronchial involvement, oesophagotracheal fistula, Karnosky score < 50, cerebral metastases, or hepatic metastases occupying more than 30% of the liver, peritoneal carcinomatosis, associated or previously treated ear-nose-throat carcinoma, or complete resection of tumour without lymph node involvement. INTERVENTIONS 5 fluorouracil (5FU) and cisplatin (CDDP) were given in 5-day courses, once every 28 days, for a maximum of eight cycles. 5 FU, 1 g/m2, was infused for 24 hours after a water overload, during five days. Cisplatin was given either in one dose of 100 mg/m2 at the beginning of the cycle or 20 mg/m2/day over three hours for five days. Duration of treatment ranged from 6-8 months. OUTCOME MEASURES Median and actuarial survival. The subsidiary endpoint was quality of survival judged by complications of treatment, swallowing disorders, and the duration of ability to feed normally. RESULTS There was no difference in survival, either overall (median = 12 months) or in any of the strata. There were however significantly more patients with neurological (p < 0.003), haematological (p < 0.0001), and renal (p < 0.0002) complications in the treated group compared with the control group. Four patients (6%) died of complications of chemotherapy. The course of swallowing disorders did not differ between the two groups. The duration of autonomous oral feeding was exactly the same in both groups (median = 10.5 months). CONCLUSION The results suggest that 5FU and CDDP do not help in patients with squamous cell carcinoma of the oesophagus whether or not the tumour has been resected.

Treatment of cancer of the exocrine pancreas.

BACKGROUND The incidence of cancer of the exocrine pancreas varies among populations, being the fourth or fifth cause of cancer death in the West. Outcome remains poor and opinions remain divided over the optimal management of the condition. METHOD A computer literature search was made of the MEDLINE database from January 1990 to December 1997 and selected other studies. RESULTS Indications and contraindications for surgery, indications for stenting, indications for resection, the technique of palliative procedures and of resection, chemotherapy, radiotherapy, and combined treatments and other treatments are discussed and recommendations made. CONCLUSIONS Irrespective of tumor size or spread, resection if feasible gives the best survival rates. Careful patient selection is required, however, to exclude those patients for whom surgical resection has no benefit. Nonsurgical procedures including endoscopic stenting in patients with high operative risk or short survival expectancy can significantly improve quality of life. The place of adjuvant therapies remains controversial and further controlled trials are required to demonstrate their efficacy.

Treatment of Adenocarcinoma of the Pancreas With Somatostatin and Gonadoliberin (Luteinizing Hormone-Releasing Hormone)

Experimental studies have shown a significant inhibition of adenocarcinoma of the pancreas by gonadoliberin (luteinizing hormone-releasing hormone [LH-RH]) and somatostatin. The aim of this prospective randomized study was to compare the potential value of somatostatin (250 micrograms every 8 hours), LH-RH (3.75 mg monthly), or combined, to a control group. One hundred sixty-three patients with adenocarcinoma of the pancreas who did not undergo resection for cure were divided into 4 groups that did not differ in terms of clinical, biologic, or pathologic data. The mean survival times were 6 months in the LH-RH plus somatostatin group, 5.5 months in the LH-RH group, 4.3 months in the control group, and 3.8 months in the somatostatin group. However, the life-table analyses for all randomized patients, and separately according to sex, the lymph node extension, and metastatic spread were not different between groups. Improvement of patient status was observed in 20% of the patients receiving hormone therapy without any difference noted between the treatment regimens. These disappointing results may be explained by the degree of extension of pancreatic carcinoma in the patients studied. The results suggest that different hormone therapy regimens might be considered according to the age and the sex of patients, as well as to the presence or absence of hormone receptors.

5-Fluorouracil and cisplatin as palliative treatment of advanced oesophageal squamous cell carcinoma. A multicentre randomised controlled trial. The French Associations for Surgical Research.

OBJECTIVE To compare chemotherapy with no chemotherapy as palliative treatment for oesophageal squamous cell carcinoma. DESIGN Randomised study. SETTING Multicentre trial in France. SUBJECTS Of 161 patients with histologically confirmed oesophageal squamous cell carcinoma located more than 5 cm from the mouth of the oesophagus, five were withdrawn because of protocol violation. The remaining 156 patients, 149 men and 7 women, mean (SD) age 58 (9) years range 36 to 77, were randomly allocated to either a control group without chemotherapy (n = 84) or a group treated by chemotherapy (n = 72). Patients were divided into four strata: I = complete resection of the tumour but with lymph node involvement (n = 62); II = incomplete resection of tumour leaving gross tumour behind (n = 58); III = no resection because of local or regional invasion (n = 22) ; and IV = no resection because of distant metastasis (n = 14). Exclusion criteria were histologically confirmed tracheobronchial involvement, oesophagotracheal fistula, Karnosky score < 50, cerebral metastases, or hepatic metastases occupying more than 30% of the liver, peritoneal carcinomatosis, associated or previously treated ear-nose-throat carcinoma, or complete resection of tumour without lymph node involvement. INTERVENTIONS 5 fluorouracil (5FU) and cisplatin (CDDP) were given in 5-day courses, once every 28 days, for a maximum of eight cycles. 5 FU, 1 g/m2, was infused for 24 hours after a water overload, during five days. Cisplatin was given either in one dose of 100 mg/m2 at the beginning of the cycle or 20 mg/m2/day over three hours for five days. Duration of treatment ranged from 6-8 months. OUTCOME MEASURES Median and actuarial survival. The subsidiary endpoint was quality of survival judged by complications of treatment, swallowing disorders, and the duration of ability to feed normally. RESULTS There was no difference in survival, either overall (median = 12 months) or in any of the strata. There were however significantly more patients with neurological (p < 0.003), haematological (p < 0.0001), and renal (p < 0.0002) complications in the treated group compared with the control group. Four patients (6%) died of complications of chemotherapy. The course of swallowing disorders did not differ between the two groups. The duration of autonomous oral feeding was exactly the same in both groups (median = 10.5 months). CONCLUSION The results suggest that 5FU and CDDP do not help in patients with squamous cell carcinoma of the oesophagus whether or not the tumour has been resected.

Gastric carcinoma treated by chemotherapy after resection: A controlled study

A prospective controlled study of combined chemotherapy with 5-fluorouracil, vinblastine and cyclophosphamide was conducted in 53 patients with radical resection for gastric carcinoma. The patients were divided into two groups, a control group of 26 patients and a chemotherapy group of 27 patients, that were similar in regard to age, sex, location of carcinoma, type of resection and pathologic findings. No significant differences in survival rate were observed between the control group and the chemotherapy groups.

5-Fluorouracil and Cisplatin as Palliative Treatment of Advanced Oesophageal Squamous Cell Carcinoma: A Multicentre Randomised Controlled Trial

OBJECTIVE To compare chemotherapy with no chemotherapy as palliative treatment for oesophageal squamous cell carcinoma. DESIGN Randomised study. SETTING Multicentre trial in France. SUBJECTS Of 161 patients with histologically confirmed oesophageal squamous cell carcinoma located more than 5 cm from the mouth of the oesophagus, five were withdrawn because of protocol violation. The remaining 156 patients, 149 men and 7 women, mean (SD) age 58 (9) years range 36 to 77, were randomly allocated to either a control group without chemotherapy (n = 84) or a group treated by chemotherapy (n = 72). Patients were divided into four strata: I = complete resection of the tumour but with lymph node involvement (n = 62); II = incomplete resection of tumour leaving gross tumour behind (n = 58); III = no resection because of local or regional invasion (n = 22) ; and IV = no resection because of distant metastasis (n = 14). Exclusion criteria were histologically confirmed tracheobronchial involvement, oesophagotracheal fistula, Karnosky score < 50, cerebral metastases, or hepatic metastases occupying more than 30% of the liver, peritoneal carcinomatosis, associated or previously treated ear-nose-throat carcinoma, or complete resection of tumour without lymph node involvement. INTERVENTIONS 5 fluorouracil (5FU) and cisplatin (CDDP) were given in 5-day courses, once every 28 days, for a maximum of eight cycles. 5 FU, 1 g/m2, was infused for 24 hours after a water overload, during five days. Cisplatin was given either in one dose of 100 mg/m2 at the beginning of the cycle or 20 mg/m2/day over three hours for five days. Duration of treatment ranged from 6-8 months. OUTCOME MEASURES Median and actuarial survival. The subsidiary endpoint was quality of survival judged by complications of treatment, swallowing disorders, and the duration of ability to feed normally. RESULTS There was no difference in survival, either overall (median = 12 months) or in any of the strata. There were however significantly more patients with neurological (p < 0.003), haematological (p < 0.0001), and renal (p < 0.0002) complications in the treated group compared with the control group. Four patients (6%) died of complications of chemotherapy. The course of swallowing disorders did not differ between the two groups. The duration of autonomous oral feeding was exactly the same in both groups (median = 10.5 months). CONCLUSION The results suggest that 5FU and CDDP do not help in patients with squamous cell carcinoma of the oesophagus whether or not the tumour has been resected.