Saúl Rodríguez‐Ramírez

Prognostic significance of retrieved lymph nodes per specimenin resected rectal adenocarcinoma after preoperative chemoradiation therapy

BACKGROUND Histologic examination of a regional lymphadenectomy specimen ordinarily should include 12 or more lymph nodes. However, in specimens from patients who received preoperative chemoradiotherapy this number has not yet been established. METHODS From January 1990 to December 2000, 210 patients with rectal adenocarcinoma located between 0 and 10 cm from anal verge with invasion into perirectal fat, tethered or fixed to the pelvis, diagnosed by computed tomography (CT) scan and/or rectal ultrasound were included. All patients received 45 Gy+bolus infusion of 5-FU (450 mg/m2/days 1-5, 28-33 of RT) 4-8 weeks after surgery was performed. Specimens were mapped and sliced. Lymph nodes were studied under clearing or manual techniques. Five-year survival was calculated by Kaplan-Meier method and comparison of groups with log-rank test. Multivariate Cox regression analysis was performed to find risk factors affecting local control and survival. RESULTS There were 126 males and 84 females; mean age was 55.2 years. Low anterior resection was performed in 112 patients, abdominoperineal resection in 85, and pelvic exenteration in 13. Total retrieved lymph nodes numbered 2,554, of which 252 contained metastasis. The group was divided into patients with 1-10 retrieved lymph nodes (n=119) and patients with > or = 11 retrieved lymph nodes (n=91). Median follow-up was 49 months. Local recurrence was as follows: 15% in patients with specimens containing 1-10 lymph nodes and conversely 7.4% in those with > or = 11 (p=0.01). Five-year survival of patients with 1-10 lymph nodes was 48%, whereas for those with > or = 11 lymph nodes it was 69% (p=0.02). CONCLUSIONS Retrieval of at least 11 lymph nodes in the surgical specimen is not only a powerful tool to properly stage patients with rectal adenocarcinoma treated with preoperative chemoradiotherapy and surgery, but it is also of prognostic relevance in that 5-year survival and local recurrence were better in this group of patients.

Preoperative Chemoradiation Therapy and Anal Sphincter Preservation with Locally Advanced Rectal Adenocarcinoma

Preoperative irradiation has been used to produce tumor regression and allow complete resection of rectal cancer with a sphincter-saving procedure. To evaluate the associated toxicity, the response in the primary tumor, and the postsurgical morbidity in a group of patients with locally advanced rectal cancer treated with preoperative chemoradiation therapy and low anterior resection, 120 patients were treated with 45 Gy of preoperative radiotherapy and a bolus infusion of 5-fluorouracil 450 mg/m2 on days 1 to 5 and 28 to 32 of radiotherapy. Four to six weeks later, 16 lesions were found unresectable; 36 patients underwent abdominoperineal resection or pelvic exenteration, and in the remaining 68 a low anterior resection was performed. For the purpose of this study only the latter group was included. There were 38 men and 30 women, with a mean age of 54.7 ± 13.1 years. Gastrointestinal and hematologic acute toxicity grade 3 to 4 occurred in 12 and 7 patients, respectively. The mean distance of the tumor above the anal verge was 8.2 ± 2.6 cm. In 10 patients the surgical resection included neighboring pelvic organs; 16 patients (23.5%) required a temporary diverting colostomy. The main causes of surgical morbidity were clinical anastomotic leakage in seven (10%), abdominal wall infection in five (7.4%), anastomotic stenosis in three (4.5%), and intraabdominal abscess in one (1.5%). No operative deaths occurred. The postsurgical stages were as follows: no tumor in the specimen, 17 (25%); T1, 4 (6%); T2, 12 (17%); T3, 17 (25%); T4, 5 (7%); any T with N+, 9 (13%); and any T, N with M+, 4 (6%). The median and mean follow-ups were 30.0 months and 37.4 ± 25.0 months, respectively. The local recurrence rate was 2.9%, and the distant recurrence rate was 17%. The administration of preoperative chemoradiation therapy for locally advanced rectal cancer is associated with tolerable toxicity, a high rate of response in the primary tumor that allowed anal sphincter preservation, and a low rate of local recurrence.

Thrombocytosis as a predictor of distant recurrence in patients with rectal cancer.

BACKGROUND AND AIMS Thrombocytosis is frequently observed in patients with malignancy. We undertook this study to determine the prognostic value of thrombocytosis in patients with rectal cancer. METHODS We performed a retrospective study of patients undergoing low anterior resection for rectal cancer between January 2000 and March 2007. Preoperative platelet count was measured before surgery. Postoperative platelets were determined 1 month after surgery. Two-tailed p values <0.05 were considered statistically significant. RESULTS One hundred sixty three patients with rectal cancer were included in the study. Preoperative platelet count >350,000 was found in 8% of patients. Postoperative platelet count >350,000 was found in 6% of patients. Distant metastases were found in 17 patients (10.4%). Significant variables in the multivariate analyses were preoperative platelets >350,000 (p = 0.001), postoperative platelets >350,000 (p = 0.002), carcinoembryonic antigen >13 ng/dL (p = 0.003). Patients with preoperative platelet count <350,000 showed a 5-year survival rate of 81%, whereas patients with platelet count >350,000 had a 25-month survival [95% confidence interval (CI): 20-26]; p <0.001. Patients with postoperative platelets <350,000 showed a 5-year survival rate of 80%, whereas patients with platelets >350,000 showed a 3-year survival rate of 37.5% (p <0.05). CONCLUSIONS Pre- or postoperative platelet count >350,000 is associated with poor survival in patients with rectal cancer. The measurement of platelets is a clinical marker useful to define the prognosis for patients with rectal cancer.

The influence of pre-operative radiation therapy on the patterns of recurrence in rectal adenocarcinoma

From January 1976 to December 1994, we evaluated the institutional experience of local recurrence and survival in patients with rectal adenocarcinoma treated with pre-operative radiation therapy (PRT) as compared to those treated with radical surgery alone. There were 412 patients, divided into two groups: 259 patients (142 males and 117 females) in Group I and 153 patients (88 males and 65 females) in Group II. The median age was 56 years. Group I patients with locally advanced tumors, either tethered or fixed, received PRT at doses of 45 Gy delivered to the pelvis in two fields; 4 to 8 weeks later, radical surgery was performed. Patients with mobile tumors underwent radical surgery only (Group II). The operative mortality was 4.6% in Group I as compared to 1.9% in Group II (P = 0.18). At median follow-up of 89 months, there were local recurrences in 12.9% of Group I as compared to 36.2% in Group II (P = 0.0000001). The administration of PRT was associated with a low rate of local recurrence, but this improvement corresponded with a high morbidity rate, especially in patients who underwent abdominoperineal resection or pelvic exenteration.