Shigenori Nagakura

Simultaneous detection of colorectal carcinoma liver and lung metastases does not warrant resection

BACKGROUND Recent evidence suggests that metastasectomy is efficacious for selected patients with hepatic and pulmonary metastases from a colorectal primary. The aim of this study was to identify a subgroup of patients who best benefit from hepatic and pulmonary metastasectomy among those with colorectal carcinoma metastases. STUDY DESIGN We analyzed retrospectively a total of 136 patients who underwent resection of hepatic or pulmonary metastases of colorectal origin at Niigata University Medical Hospital between 1982 and 2000. The median follow-up period was 94 months. Eighty-four patients underwent hepatectomy alone, 25 underwent pulmonary resection alone, and 27 underwent both hepatic and pulmonary resection. The 27 patients undergoing hepatic and pulmonary resection were divided into two groups: 17 patients with sequentially detected hepatic and pulmonary metastases and 10 patients with simultaneously detected metastases. Survival time was determined from the date of initial metastasectomy. Differences in cumulative survival were evaluated using the log-rank test. Sixteen factors were assessed for their influence on the survival of the 27 patients undergoing resection of hepatic and pulmonary metastases; univariate and multivariate analyses were used in this evaluation. RESULTS Patient survival after hepatic and pulmonary resection was comparable with that after hepatectomy alone (p = 0.536) and that after pulmonary resection alone (p = 0.294). Among the 27 patients undergoing hepatic and pulmonary resection, the outcomes after resection were significantly better in patients with sequentially detected metastases (cumulative 5-year survival of 44%) than in those with simultaneously detected ones (cumulative 5-year survival of 0%) (p < 0.001). On multivariate analysis sequential detection of hepatic and pulmonary metastases was the strongest independent favorable prognostic factor (p <0.001). CONCLUSIONS Patients with sequentially detected hepatic and pulmonary metastases from a colorectal primary are good candidates for aggressive metastasectomy. Simultaneous detection of these metastases does not warrant resection.

Multiple Repeat Resections of Intra- and Extrahepatic Recurrencesin Patients Undergoing Initial Hepatectomy for Colorectal CarcinomaMetastases

Recent evidence suggests that single repeat metastasectomy may provide survival benefits for selected patients experiencing hepatic or pulmonary recurrences following initial hepatectomy for colorectal carcinoma metastases. The aim of this retrospective study was to clarify the efficacy of multiple repeat resections of intra- and extrahepatic recurrences following initial hepatectomy. A total of 100 patients underwent curative partial hepatectomy as the initial procedure for colorectal carcinoma metastases. Tumor relapse after initial hepatectomy was seen in 72 patients, of whom 28 underwent 45 repeat metastasectomies of various sites: 18 patients underwent a single repeat metastasectomy, and 10 underwent multiple repeat metastasectomies. The overall survival rate at 5 years after initial hepatectomy was 36.6%, while the 5-year survival rate after repeat metastasectomy in the 28 patients was 43.6%. The outcome of initial hepatectomy was comparable with that of repeat metastasectomy (p = 0.6924). Among the 28 patients undergoing repeat metastasectomy, the outcome of resection of intrahepatic recurrences in 11 patients was comparable with the outcome of resection of extrahepatic recurrences in 17 patients(p = 0.3926). The outcome of multiple repeat metastasectomies compared favorably with single repeat metastasectomy(p = 0.1803). Multivariate analysis(p < 0.0001) showed that repeat metastasectomy was the strongest prognostic factor. In conclusion, both single and multiple repeat resections of intra- and extrahepatic recurrences after initial hepatectomy are efficacious in colorectal carcinoma patients. Repeat resection should be considered for any resectable recurrences after hepatectomy.

Pseudo-Meigs’ Syndrome Caused by Secondary Ovarian Tumors from Gastrointestinal Cancer

Background: Pseudo-Meigs’ syndrome is a condition characterized by nonmalignant ascites and/or pleural effusion caused by pelvic tumors other than solid benign ovarian tumors. This syndrome has only rarely occurred in association with gastrointestinal cancers. Method: We treated a 53-year-old woman who developed this syndrome due to ovarian metastasis from colon cancer. Diagnostic work-up for abdominal distension disclosed a sigmoid colon cancer and bilateral ovarian masses. Ultrasonography demonstrated massive ascites and a right pleural effusion. Repeated cytologic examinations of both effusions revealed no malignant cells. Laparotomy disclosed no peritoneal dissemination. A radical sigmoidectomy and hysterectomy with bilateral salpingo-oophorectomy were performed. Results: Histologic examination confirmed ovarian metastases from the colonic primary tumor. After resection, both effusions disappeared promptly, confirming a diagnosis of pseudo-Meigs’ syndrome caused by sigmoid colon cancer. The patient remains alive with disease after 52 months. Conclusion: Among 6 reported occurrences with gastrointestinal tumors including our case, the primary site was the colon or rectum in 5 and the stomach in 1. Two cases were due to Krukenberg tumors. Three patients with documented outcomes were alive 108, 52, and 12 months after resection. Clinicians should note that gastrointestinal cancers, especially colorectal tumors, rarely may cause pseudo-Meigs’ syndrome and resection may provide long-term palliation.

Jaundice at presentation heralds advanced disease and poor prognosis in patients with ampullary carcinoma.

Jaundice is a common manifestation of ampullary carcinoma. The aim of this study was to evaluate the correlation between jaundice at initial presentation and the degree of tumor spread and to determine the prognostic significance of jaundice in patients with ampullary carcinoma. Fifty-nine patients who had undergone curative resection for ampullary carcinoma were analyzed retrospectively. Jaundice was defined as a total bilirubin serum concentration of ≥ 3 mg/dl. The median follow-up time was 106 months. Jaundice was noted at the time of initial presentation in 43 (73%) patients. Jaundice at presentation correlated with lymph node metastasis (p < 0.0001), lymphatic vessel invasion (p < 0.0001), invasion into the pancreas (p = 0.0007), and vascular invasion (p = 0.0487). Pancreatic invasion was absent in patients without jaundice. Superior mesenteric nodal involvement was more frequent in patients with jaundice (15/43) than in those without (0/16) (p = 0.0062). The survival of patients with jaundice (median survival 48 months; cumulative 10-year survival rate 39%) was worse than for patients without jaundice (median survival time not available; cumulative 10-year survival rate 86%) (p = 0.0014). In conclusion, jaundice at presentation predicts advanced-stage ampullary carcinoma and a poor prognosis. Pancreatic invasion and superior mesenteric nodal involvement were not observed in nonjaundiced patients.

Long-Term Survival After Resection of Colonic Adenocarcinoma With Synchronous Metastases to the Liver, Adrenal Gland, and Aortic-Caval Lymph Nodes

A lthough isolated colorectal carcinoma liver metastases are good candidates for hepatic resection, simultaneous hepatic and extrahepatic metastases pose a challenging problem for surgeons. Some patients with simultaneous hepatic and pulmonary metastases may occasionally survive five years after resection. There have been no reports of long-term survival after resection of simultaneous metastases to the liver and multiple extrahepatic organs. We report a long-term survivor who underwent resection of colonic adenocarcinoma with interval resection of simultaneous metastases to the liver, right adrenal gland, and aorticcaval lymph nodes. REPORT OF A CASE

Computed tomographic features of colorectal carcinoma liver metastases predict posthepatectomy patient survival.

PURPOSE: The gross appearance of colorectal carcinoma liver metastases reflects the biologic behavior of the tumor, yielding prognostic information. The aims of this retrospective study were to determine whether preoperative computed tomographic features of colorectal carcinoma liver metastases reflect the gross appearance of resected specimens and whether these computed tomographic hepatic features predict survival after hepatectomy. METHODS: Eighty-five patients underwent curative partial hepatectomy for colorectal carcinoma liver metastases. Preoperative computed tomographic features of the largest hepatic deposit were classified by the contour of advancing margin of the tumor into two types: lobular tumors with indentations with an acute angle and nonlobular tumors without such indentations. The correlation between computed tomographic features and 18 other clinicopathologic factors was examined. RESULTS: The overall five-year survival rate was 34.1 percent. Of 85 hepatic tumors examined, 49 were lobular and 36 were nonlobular. Computed tomographic features correlated significantly with gross appearance (P=0.007). Univariate analysis revealed that computed tomographic features (P<0.0001), gross appearance (P=0.0063), size of the largest hepatic deposit (P=0.0075), age (P=0.0140), and satellite lesions (P=0.0443) were significant prognosticators. The five-year survival rates in patients with lobular and nonlobular tumors were 10.4 and 66.1 percent, respectively. By multivariate analysis, computed tomographic features (P<0.0001) and size of the largest hepatic deposit (P=0.0419) were independently significant. CONCLUSIONS: Computed tomographic features of colorectal carcinoma liver metastases correlate with their gross appearance. The computed tomographic characterization of liver metastases is the most important independent prognostic factor in patients undergoing curative hepatectomy.